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RA MONITORING SYSTEM CE TIFI AT1 MAKE / MODEL OF MONITORING SYSTEM: GlIbarco EMC CERTIFICATION /TEST DATE: August 08, 2018 AI IG 1 7 Al. FACILITY DIS PENS ERS/U Tank #2 (Product): Gasoline - 91 A2. OWNER IIE:�I;CII I Name Quik Stop Market # 39 Model: 1111:N"1'AL Name Quik Stop 6hk ,�I�t�. 2 UN5 Address 2285 E. Fremont Street, Stockton, CA 95205 ■ ti Address 4567 Enterprise Streel�,�i>►��j,tA` 8 Phone # 510-657-8500 Annular Space or Vault Sensor Phone # 510-657-8500 Contact Roger Batra Model: 0794380-208 Contact Debbie Markovich A3. C U P A 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 25, 2018 Lic # 617238 A, B, Haz Inspector Arron Hang Contact Veronica Freitas Phone # 209-468-3442 Phone # 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) B1: TANKS Tank #1 (Product): Gasoline - 87 DIS PENS ERS/U Tank #2 (Product): Gasoline - 91 Dispenser # : 1-2 ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: ■ ti Annular Space or Vault Sensor Model: 0794380303 ■ Annular Space or Vault Sensor Model: 0794380-303 ■ 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: VMI 99LD-2000 ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: , ❑ Tank Overfill / High -Level Sensor Model:❑ ❑ Dispenser Containment Float(s) and Chain(s) Tank Overfill / High -Level Sensor Model: ❑ Other specify equipment in Section E) Modal: X❑ Other (specify equipment in Section E) Model: 7777777777777-777 Tank #3 (Product): _ Tank #4 (Product): ❑ In -Tank Gauging Probe Model: ,; ❑ In -Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump / Trench Sensor(s) Model: ❑ Piping Sump / Trench Sensor(s) Model: ti =i ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Model ❑ 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: LEI Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: 132: DIS PENS ERS/U DC's Dispenser # : 1-2 Dispenser # : 3-4 ■ Dispenser Containment Sensor(s) Model: 0847990-001 ■ Dispenser Containment Sensor(s) Model: 0847990-001 ■ Shear Valves ■ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) Dispenser #: Dispenser # ❑ Dispenser Containment Sensor(s) Model: n ❑ Dispenser Containment Sensor(s) Model: _ ❑ Shear Valves _ ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ': ❑ Dispenser Containment Float(s) and Chain(s) F Dispenser # : Dispenser # . t�. ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ;' ❑ Shear Valves E]Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(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 ALTON Signature: rial"Felour., mc. Technician / Cert M Curtis Carpenter / 837258 8020679 Date: August 8, —7018