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MONITORING SYSTEM CERTIFICATICYff-'-" MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 .,iUN 14 2017 CERTIFICATION /TEST DATE: June 9, 2017 Al. FACILITY 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 Phone # 510-657-8500 Contact Roqer Batra Contact Debbie Markovich A3. C U P A Tank #2 (Product): 91 A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Model: Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 Annular Space or Vault Sensor Address P.O. Box 1025, W. Sacramento, CA 95691 Notified May 24, 2017 Lic # 617238 A, B, Haz Inspector Yes Model: 0794380-208 Contact Veronica Freitas Phone # 209-468-3442 Fill Sump Sensor(s) Phone # 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) B7: 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 Ii Annular Space or Vault Sensor Model: 0794390-309 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: Mechanical Line Leak Detector Model: VMI 99LD-2000 N 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: ❑ Dispenser Containment Float(s) and Chain(s) Tank #3 (Product): Diesel 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: 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 ■ Svstem set-up N Alarm History Report Signature: ' - ALTON ENGINEERING, INC. Technician / Cert M Scott Beall / B45116 8319310 Date: June 9, 2017 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, I have also attached a copy of the report; (check all that apply ■ Svstem set-up N Alarm History Report Signature: ' - ALTON ENGINEERING, INC. Technician / Cert M Scott Beall / B45116 8319310 Date: June 9, 2017