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og :4 1 o Levym ig ivi teig aan CERTIFICATION / TEST DATE: June 10, 2016 APR 16 2016 {^in✓Yy 1, ^.'.� `r^-? .4,�, ,a� .<., .s a nMMT DE IMP-TWOMM A7. FACILITY Yes A2. OWNER Name Quik Stop Market #125 Has all input wiring been inspected for proper entry and termination, including testing for ground faults? 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 Roger Batra No* Contact Debbie Markovich Win -�1.19r V�INWI� ,��i� _ "' ` - ` X°k 11?h`,Ie� 1I�4� �.'� �t ora,. �titi ""`5�;='a:�' ?�; ,.r.�.,.-._._�._ -.. _... �7 _@1 7T 7 -_*77, 7M . 4.. 7 m� 1 F. IN -TANK GAUGING / SIR EQUIPMENT: ❑ ■ Check this box if tank gauging is used only for inventory control. Was accuracy of system product level readings tested? ❑ ❑ Check this box if no tank gauging or SIR equipment is installed. This section must be completed if in -tank gaugung equipment No* is used to perform leak detection monitoring. Complete the following checklist: Yes ❑ * In Section H below, describe how and when these deficiencies were or will be corrected. G. LINE LEAK DETECTORS (LLD): ❑ Check this box if LLDs are not installed. Complete the following checklist: ai:`c.;...7 ::..____EMMUI nMMT DE IMP-TWOMM ❑ Yes ❑ No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? ❑ NIA ❑ Yes ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup? ❑ Yes ❑ No* Was accuracy of system product level readings tested? ❑ Yes ❑ No* Was accuracy of system water level readings tested? ❑ Yes ❑ No * Were all probes reinstalled properly? ❑ Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? * In Section H below, describe how and when these deficiencies were or will be corrected. G. LINE LEAK DETECTORS (LLD): ❑ Check this box if LLDs are not installed. Complete the following checklist: ai:`c.;...7 ::..____EMMUI ✓hep:,'.. I °..1M. ■ Yes ❑ No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? ❑ NIA (check all that apply) Simulated leak rate: ■ 3g.p.h.; ❑ 0.1 g.p.h.; ❑ 0.2g.p.h. ■ Yes ❑ No* Were all LLDs confirmed operational and accurate within regulatory requirements? ■ Yes ❑ No* Was the testing apparatus properly calibrated? ■ Yes ❑ No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak? ❑ N/A z ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? ■ NIA ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled ■ N/A or disconnected? i ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions ® N/A or fails a test? ❑ Yes ❑ No* For electronic LLDs, have all accessible wiring connections been visually inspected? ® N/A ■ Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? * In Section H below, describe how and when these deficiencies were or will be corrected. MW H. COMMENTS Page 3 of 3