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MONITCRING SYSTEM CERTIFI ACCEIVED MAKE/MODEL OF MONITORING SYSTEM: Veeder-Root L CERTIFICATION/TEST DATE: Au ust 20, 2014 Al. U 111' FACILITY A2. OWNER Name Quik Stop Market#138 Name Quik Stop Markets Inc nn''^^//��nn��p� HEALT Address 1153 Lincoln Blvd.,Tracy,CA 95376 Address 4567 Enterpri;aQb rtt`6h'It,`C'A'914538 Phone# 510-657-8500 Phone# 510-657-8500 DEPARTMENT Contact Roger Batra 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 August 06,2014 Lic# 617238 A,B,Haz Inspector Stacy Rivera Contact Dulcinea Coven Phone# 209-468-8257 Phone# 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (check the appropriate boxes to Indicate equipment Inspected/serviced) B7: 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: 0794360-206 ■ Piping Sump/Trench Sensor(s) Model: 0794380-206 ❑ 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: ❑ Tank Overfill/High-Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment In Section E) Model: Tank#3 (Product): Gasoline-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: B2: DISPENSERS/UDC's Dispenser#: 1-2 Dispenser#: 3-4 ❑ 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 Chain(s) Dispenser#: Dispenser#: ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s)and Chaln(s) ❑ Dispenser Containment Float(s)and Chains) 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 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 verity 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 II ■ System set-up ■ Alarm History Report ` "" W e WALTON Signature: 01� ENGINEERING,INC. Technician/Cert#: Jessie Wadkins/B35391 5307886-UT Date: August 20,2014 2014 Walton Engineering,Inc.