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• ' i CERTIFICATION /TEST DATE: July 24, 2017 JUL`, A1. FACILITY A2. OWNERawl �-( Name Quik Stop Market #144 Name Quik Stop MjAWP Address 7272 West Lane, Stockton, CA 95210 Address 4567 Enterprise Street, 66pow, CAFMU Phone # 510-657-8500 Phone # 510-657-8500 Contact Roger Batra Contact Debbie Markovich F. IN -TANK GAUGING / SIR EQUIPMENT: ■ Check this box if tank gauging is used only for inventory control. ❑ Check this box if no tank gauging or SIR equipment is installed. This section must be completed if in -tank gaugung equipment is used to perform leak detection monitoring. Complete the following checklist: * In Section H below, describe how and when these deficiencies were or will be corrected. G. LINE LEAK DETECTORS (LLD): Complete the following checklist: E] Check this box if LLDs are not installed. ■ Yes ❑ No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? ❑ Yes ❑ No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? El Yes F1 No* Were all tank gauging probes visually inspected for damage and residue buildup? El Yes El No* Was accuracy of system product level readings tested? ❑ Yes El No* Was accuracy of system water level readings tested? El Yes El No* Were all probes reinstalled properly? ❑ Yes ElNo* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? ■ N/A * In Section H below, describe how and when these deficiencies were or will be corrected. G. LINE LEAK DETECTORS (LLD): Complete the following checklist: E] Check this box if LLDs are not installed. ■ Yes ❑ No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? El N/A (check all that apply) Simulated leak rate: 3 g.p.h.; El 0.1 g.p.h.; El 0.2 g.p.h. ■ Yes ElNo* Were all LLDs confirmed operational and accurate within regulatory requirements? ■ Yes ElNo* Was the testing apparatus properly calibrated? ■ Yes ElNo* For mechanical LLDs, does the LLD restrict product flow if it detects a leak? ❑ Yes El No * Were all items on the equipment manufacturer's maintenance checklist completed? * In Section H below, describe how and when these deficiencies were or will be corrected. G. LINE LEAK DETECTORS (LLD): Complete the following checklist: E] Check this box if LLDs are not installed. ■ Yes ❑ No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? El N/A (check all that apply) Simulated leak rate: 3 g.p.h.; El 0.1 g.p.h.; El 0.2 g.p.h. ■ Yes ElNo* Were all LLDs confirmed operational and accurate within regulatory requirements? ■ Yes ElNo* Was the testing apparatus properly calibrated? ■ Yes ElNo* For mechanical LLDs, does the LLD restrict product flow if it detects a leak? El N/A ❑ Yes ElNo* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? ■ N/A El Yes ElNo* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled ■ N/A or disconnected? El Yes ElNo* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions ■ N/A or fails a test? El Yes ❑ No* For electronic LLDs, have all accessible wiring connections been visually inspected? ■ N/A ■ Yes ElNo* Were all items on the equipment manufacturer's maintenance checklist completed? * In Section H below, describe how and when these deficiencies were or will be corrected. H. COMMENTS Page 3 of 3