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INVINONITURING SYSTEM CETIFIATIQ LL L' MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -35 CERTIFICATION / TEST DATE: June 10, 2016 APR I A MG k,�:'. , ✓.x. ��£. � °'" _ .a�......W a .wu p - 'Fzaa �p��.., ..,: ...,ayi.�.; � '. � 5 ., h eierx`'�°�-�`—'"�`�".lK>^ `� :£:, r..> l irva ' �� A7. FACILITY A2. OWNER �p Name Quik Stop Market #125 Name Quik Stop Markets, Inc.\. a Lk, \ NL --v Address 1580 W. Main Street, Ripon, CA 95366 Address 4567 Enterprise Street, Fremont, CA 94538 Phone # 510-657-8500 Phone # 510-657-8500 1. Contact Roger Batra = Contact Debbie Markovich A3. C U P A A4. TESTING CONTRACTOR _- Name San Joaquin County Environmental Health 1 I Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 = Address P.O. Box 1025, W. Sacramento, CA 95691 Notified May 25, 2016 Lic # 617238 A, B, Haz Inspector Elena Manzo 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 _NO .sR.,",. 225b £ ,. .. Tank #1 (Product): Gasoline - 87 1 Tank #2 (Product): Gasoline - 91 ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: ti N �� II Annular Space or Vault Sensor Model: 0794390-409i Annular Space or Vault Sensor Model: 0794390-409 N 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: II Mechanical Line Leak Detector Model: VMI 99LD-2000 Mechanical Line Leak Detector Model: Red Jacket FX z ❑ Electronic Line Leak Detector Model El Electronic Line Leak Detector Model: ❑ Tank Overfill / High -Level Sensor Model - --- ElTank Overfill / High -Level Sensor Model: g ❑ 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: Annular Space or Vault Sensor Model: 0794390-409 ❑ Annular Space or Vault Sensor Model: Pim Sum / Trench Sensors Model: 0794380-208 P�9 p l) ❑ Pim Sum / Trench Sensors Model: Piping P O _ ❑ 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 ad I Dispenser #: 1-2 Dispenser #: 3-4 ❑ Dispenser Containment Sensor(s) Model: r ❑ 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 Cham(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) _ 0000 E ."00M 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 Histo Report 4 + WALTON Signature: (jf NGINURING, INC. Technician/ ert#: Jessie Wadkins / B35391 5307886 -UT Date: June 10, 2016 w _ 0 2016 Walton Engineering, Inc.