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MONIT(WING SYSTEM CERTIFWATION <br /> MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 <br /> CERTIFICATION /TEST DATE: May 25, 2011 <br /> Al. FACILITY A2. OWNER <br /> Name Quik Stop Market#120 Name Quik Stop Markets, Inc. <br /> Address 9321 Thornton Road,Stockton,CA 95209 Address 4567 Enterprise Street, Fremont,CA 94538 <br /> Phone# 510-657-8500 Phone# 510-657-8500 <br /> Contact Michael Karvelot Contact Michael Karvelot <br /> A3. C U P A A4. TESTING CONTRACTOR <br /> Name San Joaquin County Environmental Health Name Walton Engineering, Inc. <br /> Address 600 E. Main Street,Stockton,CA 95202 Address P.O.Box 1025,W.Sacramento,CA 95691 <br /> Notified May 4,2011 Lic# 617238 A,B,Haz <br /> Inspector Garrett Backus Contact Dulcinea Covan <br /> Phone# 209-468-8257 Phone# 916-373-1166 <br /> B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspectediserviced) <br /> 131: TANKS <br /> Tank#1 (Product): Gasoline-87 Tank#2 (Product): Gasoline-91 <br /> ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: <br /> ■ Annular Space or Vault Sensor Model: 0794380-301 ■ Annular Space or Vault Sensor Model: 0794380-301 <br /> ■ Piping Sump/Trench Sensor(s) Model: 0794380-208 ■ Piping Sump I Trench Sensor(s) Model: 0794380-208 <br /> ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: <br /> ■ Mechanical Line Leak Detector Model: VMI 99LD-2000 ■ Mechanical Line Leak Detector Model: VMI 99LD-2000 <br /> ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: <br /> ❑ Tank Overfill/High-Level Sensor Model: ❑ Tank Overfill/High-Level Sensor Model: <br /> ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: <br /> Tank#3 (Product): Tank#4 (Product): _ <br /> ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: <br /> ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: <br /> ❑ Piping Sump I Trench Sensor(s) Model: ❑ Piping Sump/Trench Sensor(s) Model: <br /> ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: <br /> ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: <br /> ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: <br /> ❑ Tank Overfill I High-Level Sensor Model: ❑ Tank Overfill/High-Level Sensor Model: <br /> ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: <br /> 132: DISPENSERS/UDC's <br /> Dispenser#: 1-2 Dispenser#: 3-4 <br /> ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: <br /> ■ Shear Valves ■ Shear Valves <br /> ■ Dispenser Containment Float(s)and Chain(s) ■ Dispenser Containment Float(s)and Chain(s) <br /> Dispenser#: Dispenser#: <br /> ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: <br /> ❑ Shear Valves ❑ Shear Valves <br /> ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) <br /> Dispenser#: Dispenser#: <br /> ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: <br /> ❑ Shear Valves ❑ Shear Valves <br /> ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) <br /> C. CERTIFICATION I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers'guidelines. <br /> Attached to this Certification is information(e.g.manufacturers'checklists)necessary to verify that this information is correct and a Plot Plan showing the <br /> 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): <br /> ■ System set-up ■ Alarm History Report <br /> WALTON <br /> Signature:9 �'2.GZ'G"G� ENGINEERING,MC. <br /> Technician/Cert#: Curtis Carpenter/B37258 8020679 Date: May 25,2011 <br /> LZ2011 Watton Engineering.Inc. <br />