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MONIT RING SYSTEM CERTIFICATION SEP u 1 zu�s MAKE ! MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 r�l�wi CERTIFICATION /TEST DATE: Jul 30, 2015 Al. FACILITY A2, OWNER Name Quik Stop Market 0144 Name Quik Stop Markets, Inc. Address 7272 West Lane, Stockton, CA 95310 Addrasa 4116? Enterprise Street, Frsrnord, CA 94838 Phone # 510.657.8600 Phone # 510.667-8800 contact R Batts contact Dabble Markovich A3. C U P A A4. TESTING CONTRACTOR Marc* San Joaquin County Environmental health Norse Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 Address P.O. Box 1038, W. Sacramento, CA 96691 Nomd July 14, 2016 Lic # 617238 A, B, Ha: Inspector Fatinah 2arsef Contact Veronica Freitas Phone # 2011468.8257 Phone a 910.373-1166 N. INVENTORY OF EQUIPMENT TESTEDICERTIFIED(Checkthsapproprglbboxes toIndicate equipmentinspectedharvlceM 131: TANKS Tank Ni (Product): Gasoline - 87 Tardt #2 (Product): Gasoline - 89 ❑ In-Tank Gauging Probe Madel: ❑ In-Tank Gauging Probe Model ■ Annular Space or Vauft Sensor Model: 0798390.409 ■ Annular Space or Vault Sensor Modal. 07043004400 ■ Piping Sump I Trench Seenor(a) Model: 0794390.208 ■ Piping Swap! Trench Sonsor(s) Model: 0794380.208 ❑ Fill Sump Sansor(s) Model: - _ ❑ fdi Sumlp sensor(a) Model: ■ Mechanical Lina Leek Detector Model: VAI 99LD4W ■ Msclanical Lina Lack Detector Model: Fred Jw*ot FJ( ❑ Electronic Line Leak Reactor Model: ❑ Electrente Una Leak Detector Model: ❑ Tank OvwU i i gh-Leval Senior Model ❑ Tsnk Oveerlitl i HWt-Leval Sensor Model: 4 (3 Other I specly o"lism"t In Section Er} Model: ❑ Other lepecily equipment in Section E) Model: Tank #3 (Product): Gasoline - 91 Tank 04 (Product): ❑ in-Tank Gauging Probe Modell:❑' _ in-Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Modell 0704390409 ❑ Anawar Space or Vault Sensor Model: ■ Pipkkg Swap f Trench Souse**) Mode. 070430040/ } ❑ Piping Sump 1 Trench Sensor(*) Model: ❑ Fill Sump Sarrsor(s) Model ❑ Fel Sump Sensors) Model: -- ■ Mechanical Line Leek Detector Model. VMl s Lc4illo❑ Mechanical Una, Leak Detector Model: ❑ Electronic Lkw Leak Detector Model. ❑ Electronic Una Leak Detector Model: _. Tank overfill i Mth•Level Sensor Modsk ❑ Tank Overfill / High-Levet Sensor Model Other (specify equipment In Section E)Model ❑ Other (olwily, equipment in Section E) Mlodat. 'i e... �.� ...-....-�..,... 82; DISPENSERSIUDC's Dispenser 0 : 1-2 Dispenser #: 3-4 ■ Dispenser Containment Senores) Model: 0704390400 ■ Dispenser Containment Sensors) Model 07MI110400 mm _ ■ Shaer Vatves ❑ Dispenser Containment Floats) and Chaln(s) ■ Shear Valves C3 Dispenser containment Floags) and Chatn(s) Dispenser 0 : 11.6 Dispenser # ■ Dispenser Comislament Sensonisl Model: 0794300.200 ❑ Dispenser Containment Senser(s) Model: ■ Shear Valves ❑ Shear Valves ❑ Dlapenesr Containment Fks#tl*)and chaln(s) ❑ Dispenser Containment Float(s) and Chain(*) -- — ----- -- – --.. Drspensar # : Dispenser III[: ❑ Dispeaw containment Satnoor(a) Madel ❑ olspemarcontainment Sensor(*) Model: Shear Valves ❑ Sheer Valves _ .�— ❑ Dispenser Containment Flo"s) anit Chili") , ❑ Dkkpenaer Containment Float(s) and Chains) C. CERTIFICATION I Certify that the equipment identified In this; document vara to*peeadborrviced In accordance with the mratullockarwrs' gumsllnes. Aeochsd to aft CwWcaaon Is in(srnetion (e g. ntaralfadurers' dwckBsb) necessary, to verify get this Information Is correct end a Plot Plan showkt0 the layout of monitoring equip muM For any equipment capable of gensratlnp ouch roporb, I have ala* allschtd a copy ofths report; (check all that apply): Systern set-up ■ Alarm Histc Report signal": ENGINEERING, INC. Technician t C4"1#: Jeeeb womm 1 B38M 8307'88 WT Date. ,)rely 30, 2015