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i MONITORING SYSTEM CERTIFICATION—°J"a V I— MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 AUG 112014 CERTIFICATION / TEST DATE: Auqust 1, 2014 Al. FACILITY A2. OWNER ENVIRONMENTAL HEAL Name Quik Stop Market #144 Name Quik Stop Markets, Inc. jo&f T Address 7272 West Lane, Stockton, CA 95210 Address 4567 Enterprise Street, Fre on , A 8 Phone # 510-657-8500 Phone # 510-657-8500 Contact Roger Batra Contact Debbie Markovich A3. C U P A INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to Indicate equipment Inspected/serviced) A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 Address P.O. Box 1025, W. Sacramento, CA 95691 Notified July 16, 2014 Lic # 617238 A, B, Haz Inspector Jeff Wong ❑ Contact Dulcinea Coven Phone # 209-468-8257 In -Tank Gauging Probe Phone # 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to Indicate equipment Inspected/serviced) Bi: TANKS Tank #1 (Product): Gasoline - 87 Tank #2 (Product): Gasoline - 89 ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390-409 ■ Annular Space or Vault Sensor Model: 0794390-409 ■ Piping Sump / Trench Sensor(s) Model: 0794380-208 ■ Piping Sump / Trench Sensor(s) Model: 0794380-208 ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ■ Mechanical Line Leak Detector Model: VMI 99LD-2000 ■ Mechanical Line Leak Detector Model: Red Jacket FX ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill / High -Level Sensor Model: ❑ Tank Overfill / High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: Tank #3 (Product): Gasolie - 91 Tank #4 (Product): ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390-409 ❑ Annular Space or Vault Sensor Model: ■ Piping Sump / Trench Sensor(s) Model: 0794380-208 ❑ Piping Sump / Trench Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ■ Mechanical Line Leak Detector Model: VMI 99LD-2000 ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill / High -Level Sensor Model: ❑ Tank Overfill / High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: 62: DISPENSERS/UDC's Dispenser # : 1-2 Dispenser # : 3-4 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chaln(s) Dispenser # : 5-6 Dispenser # ■ Dispenser Containment Sensor(s) Model: 0794380.208 ❑ Dispenser Containment Sensor(s) Model: ■ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chaln(s) ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chaln(s) C. CERTIFICATION I certify that the equipment Identified In this document was inspected/serviced In accordance with the manufacturers' guidelines. Attached to this Certification Is Information (e.g. manufacturers' checklists) necessary to verify that this information Is correct and a Plot Plan showing th layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply ■ System set-up ■ Alarm History Report WALTON Signature: OVW ' U+ ENGINEERING. INC. Technician / Cert #: Jessie Wadkins / B35391 5307886 -UT Date: August 1, 2014