COMPLIANCE INFO_2012-2018 - Laserfiche WebLink

Home Browse Search

MONITORING SYSTEM CERTIFICATION° �� "5"" ,:y `mxw MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 (% Y'{ 3 i 2017 CERTIFICATION /TEST DATE: May 25, 2017 A1. FACILITY Name Name Quik Stop Market #121 Address 1196 W. Louise Avenue, Manteca, CA 95336 Phone # 510-657-8500 Contact Roger Batra A3. CUPA Name San Joaquin County Environmental Health Address 1868 E. Hazelton Avenue, Stockton, CA 95202 Notified May 10, 2017 Inspector Aaron Hang Phone # 209-468-3442 A2. OWNER L -Iv V InUIViV�;e.IN I,'�L r11 Name Quik Stop Markets, Inc. 1.)FRARTNIENT Address 4567 Enterprise Street, Fremont, CA 94538 Phone # 510-657-8500 Contact Debbie Markovich A4. TESTING CONTRACTOR Name Walton Engineering, Inc. Address P.O. Box 1025, W. Sacramento, CA 95691 Lic # 617238 A, B, Haz Contact Veronica Freitas 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 Tank #2 (Product): Gasoline -91 ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: • Annular Space or Vault Sensor Model: 0794380-303 Annular Space or Vault Sensor Model: 0794380303 • 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: 0 Mechanical Line Leak Detector Model: VMI 99LD-2000 Mechanical Line Leak Detector Model: FE Petro STP -MLD ❑ 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): 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: ❑ 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: ❑ 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 # : 5-6 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) 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 verify that this information is correct and a Plot Plan showing th layout of monitoring equipment. For any equipment capable of generating such reports, 1 have also attached a copy of the report; (check all that apply ■ System set-up ■ Alarm History Report y WALTON Signature: /_) %� �"` ��- ENGINEERING, INC. Technician / Cert #: Anthony Reyes 645115 8293772 Date: May 25, 2017