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MONITORING SYSTEM CERTIFICATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION/ TEST DATE: June 06, 2018 A1. FACILITY INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) A2. OWNER Name Quik Stop Market #125 Name Quik Stop Markets, Inc. Address 1580 W. Main Street, Ripon, CA 95366 ❑ Address 4567 Enterprise Street, Fremont, CA 94538 Phone # 510-657-8500 Model: Phone # 510-657-8500 Contact Roger Batra Annular Space or Vault Sensor Contact Debbie Markovich A3. C U P A Model: 0794380-208 Model: ❑ A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Mechanical Line Leak Detector Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 ❑ Address P.O. Box 1025, W. Sacramento, CA 95691 Notified May 23, 2018 Model: Lic # 617238 A, B, Haz Inspector Zuna Barker Tank Overfill / High -Level Sensor 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): 87 Tank #2 (Product): 91 ❑ 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) Fill Sump Sensor(s) Model: 0794380-208 Model: ❑ Piping Sump / Trench Sensor(s) Fill Sump Sensor(s) Model: 0794380-208 Model: 0 Mechanical Line Leak Detector Model: VMI 99LD-2000 0 Mechanical Line Leak Detector Model: Red Jacket FX ❑ 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): Diesel Tank #4 (Product): _ ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: 0 Annular Space or Vault Sensor Model: 0794390-409 ❑ Annular Space or Vault Sensor Model: 0 Piping Sump / Trench Sensor(s) Model: 0794380-208 ❑ Piping Sump / Trench Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: I� 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 # : 5-6 ❑ 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, I have also attached a copy of the report; (check all that apply ■ System set-up ■ Alarm History Report JJ0 WALTON Signature: - ; -, rk'�t � � ENGINEERING, INC. Technician / Cert #: Anthony Reyes B46116 8293772 Date: June 6, 2018