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;L MONITTRING SYSTEM CERTIFICATION JUN 0 7 2016 MAKE I MODEL OF MONITORING SYSTEM: Gilbarco EMC CERTIFICATION /TEST DATE: June2,2016 'A 000-01 11 -_ - 11 n,5N Al. FACILITY 11 A2. OWNER Name Quik Stop Market #121 Name Quik Stop Markets, Inc. Address 1196 W. Louise Avenue, Manteca, CA 95336 Address 4567 Enterprise Street, Fremont, CA 94538 -1 Phone # 510-657-8500 Phone# 510-657-8500 p Contact Roger Batra Contact Debbie Markovich A3. C U P A I A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202Address Notified May 18, 2016 P.O. Box 1025, W. Sacramento, CA 95691 Lic # 617238 A, B, Haz Inspector Elena Manzo Contact Veronica Freitas Phone # 209-468-3442 Phone# 916-373-1166 IN,, B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) Ell: TANKS It Tank #1 (Product): Gasoline - 87 Tank #2 (Product): Gasoline - 91 2 El In -Tank Gauging Probe Model: El In -Tank Gauging Probe Model: 1 P Annular Space or Vault Sensor Model: 0794380-303 Annular Space or Vault Sensor Model: 0794380-303 Piping Sump /Trench Sensor(s) Model: 0794380-208 1� Piping Sump /Trench Sensor(s) Model: 0794380-208 R, j El Fill Sump Sensor(s) Model: -,T El Fill Sump Sensor(s) Model: 6 Mechanical Line Leak Detector Model: VMI 99LD-2000 M Mechanical Line Leak Detector Model: FE Petro STP -MLD ti El Electronic Line Leak Detector Model: El Electronic Line Leak Detector Model: El Tank Overfill I High -Level Sensor Model: E] Tank Overfill / High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: El Other (specify equipment in Section E) Model: . ......... . ... .. .. Tank #3 (Product): Tank #4 (Product): ❑ In -Tank Gauging Probe Model: J? El in -Tank Gauging Probe Model: El Annular Space or Vault Sensor Model: El Annular Space or Vault Sensor Model: N N El Piping Sump Trench Sensor(s) Model: ❑ Piping Sump Trench Sensor(s) Model: El 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: M Tank Overfill /High -Level Sensor Model: El Tank Overfill /High -Level Sensor Model: Other (specify equipment in Section E) Model: El Other (specify equipment in Section E) Model: ry --- — — - — - - -- -- ------ - ---------- - -- E12: DISPENSERS/UDC's Dispenser # 1-2 0 Dispenser # 3-4 Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: Shear Valves Shear Valves Z Dispenser Containment Float(s) and Chain(s) Dispenser Containment Float(s) and Chain(s) w -aw k -M-0 "M 'on?o Dispenser # 5-6 Dispenser #: ti El Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: Shear Valves ❑ Shear Valves Dispenser Containment Float(s) and Chain(s) El Dispenser Containment Float(s) and Chain(s) kz�= X&M—M-0 M, Dispenser # Dispenser # ❑ Dispenser Containment Sensor(s) Model: El Dispenser Containment Sensor(s) Model: El Shear Valves El Shear Valves El Dispenser Containment Float(s) and Chain(s) El Dispenser Containment Float(s) and Chain(s) PRO N 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 N System set-up 0 Alarm History Report 77-777k, mvo,, onAmMONE209 " WALTON Signature: ENGINEERING, INC. Technician Cert M Jessie Wadkins I B35391 6307886 -UT Date: ,Julie 2, 2016 NU MEW', 0 0 2016 Walton Engineering, Inc.