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MONITORING SYSTEM CERTIFICATION,. �, MAKE / MODEL OF MONITORING SYSTEM: Gilbarco EMC--•r�,�►, /�. CERTIFICATION /TEST DATE: June 10, 2015 A1. 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, IrA49d5'8.. Phone# 510-657-8500 Phone# 510-657-8500 Contact Roger Batra Contact Debbie Markovich A3. C U P A ❑ In -Tank Gauging Probe A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health In -Tank Gauging Probe Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 Model; Address P.O. Box 1025, W. Sacramento, CA 95691 Notified May 26, 2015 ■ Lic # 617238 A, B, Haz Inspector Elena Manzo Model: 0794380-208 Contact Veronica Freitas Phone # 209.468-8257 ❑ Phone # 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to Indicate equipment inspected/serviced) I 131: TANKS Tank #1 (Product): Gasoline - 87 ❑ In -Tank Gauging Probe Tank #2 (Product): Gasoline - 91 Annular Space or Vault Sensor I❑ In -Tank Gauging Probe Model: Fill SumpSensor(s) ❑ In -Tank Gauging Probe Model; ■ Annular Space or Vault Sensor Model: 0794390-409 ❑ ■ Annular Space or Vault Sensor Model: 0794390.409 ■ Piping Sump / Trench 3ensor(s) Model: 0794380-208 Model: ■ Piping Sump I Trench Sensor(s) Model; 0794380-208 ❑ Fill Sump Sensor(s) Model: ■ ❑ Fill Sump Sensor(s) Model; ■ Mechanical Line Leak Detector Model: VMI 99LO.2000 Dispenser Containment Floats) and Chaln(s) ■ Mechanical Line Leak Detector Model: Red Jacket FX ❑ Electronic Line Leak Detector Model: ❑ ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill / High -Level Sensor Model: Shear Valves ❑ Tank Overfill / High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment In Section E) Model; Tank #3 (Product): Diesel ❑ In -Tank Gauging Probe ■ Annular Space or Vault Sensor ■ Piping Sump / Trench Sensor(*) ❑ Fill SumpSensor(s) ■ Mechanical Line Leak Detector ❑ Electronic Line Leak Detector ❑ Tank Overfill I High -Level Sensor ❑ Other (specify equipment In Section Model: Model: 0794390.409 Model: 0794380-208 Model: Model: VMI 9OLD-2000 Model: Model: Model: Tank #4 (Product): _ ❑ In -Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump I Trench Sensoria) Model: ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill / High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: i-cIESEs11_ti!J:30I,Zv:3-J-Z1IsIIIOft _I C. CERTIFICATION I certify that the equipment identified In this document was inspectedlservlced 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 Piot Plan showing the 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 Wlu---- WALTON Signature: E. NGINEERING, INC. Technician / Cert #: Jessie Wadkins 11335391 5307886 -UT Date: June 10, 201.5 Dispenser # : 1-2 Dispenser # : 3-4 [I Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensors) Model: ■ Shear Valves ■ Shear Valves ■ Dispenser Containment Flosys) and Chaln(s) ■ Dispenser Containment Float(s) and Chaln(s) Dispenser # : 5-6 Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensors) Model: ■ Shear Valves ■ Shear Valves ■ Dispenser Containment Floats) and Chaln(s) ■ Dispenser Containment Floats) and Chaln(s) Dispenser #: Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chaln(s) ❑ Dispenser Containment Float(s) and Chaln(s) C. CERTIFICATION I certify that the equipment identified In this document was inspectedlservlced 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 Piot Plan showing the 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 Wlu---- WALTON Signature: E. NGINEERING, INC. Technician / Cert #: Jessie Wadkins 11335391 5307886 -UT Date: June 10, 201.5