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• MONITORING SYSTEM CERTIFICATION MAKE/ MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION / TEST DATE: September 21, 2012 A1. FACILITY A2. OWNER Name Quik Stop Market #148 Name Quik Stop Markets, Inc. Address 205 W. Lockeford Street, Lodi, CA 95240 Address 4567 Enterprise Street, Fremont, CA 94538 Phone # 510-657-8500 Phone # 510-557-8500 Contact Michael Karvelot Contact Michael Karvelot A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 Address P.O. Box 1025, W. Sacramento, CA 95691 Notified September 12, 2012 LIc # 617238 A, B, Haz Inspector Arts Cacapit Contact Dulcinea Covan Phone # 209-468411257 Phone # 9164734166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (check the appropriate boxes to indicate equipment inspectediserviced) B7: TANKS Tank #1 (Product): _ _..._} Tank#2 (Product): _ ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump I Trench Sensor(s) Model: ❑ Piping Sump i Trench Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Model: ❑ Mechanical Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill I High -Level Sensor Model ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill I High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: Tank #3 (Product): Gasoline - 91 Tank #4 (Product): _ ❑ In -Tank Gauging Probe Model: ❑ in -Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump I Trench Sensor(s) Model: ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump I Trench Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: i ❑ Fill Sump Sensor(s) Model: i■ Mechanical Line Leak Detector Model: VMI 99LO-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 Sectlon E) Model' 82: DISPENSERS/UDC's Dispenser # : 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 # I [3Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves i 1 ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chains) 1 ❑ Dispenser Containment Float(s) and Chains) Dispenser # : Dispenser # : ❑ Dispenser Containment sensor(s) Model: _ ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chaln(s) ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chains) C. CERTIFICATION Ice" that the equipment Identified in this document was inspectediserviced in accordance with the manufacturers' gukiellnes. Attached to this Certiftoon Is Information (e.g. manufacturers' checklists) necessary to verify Mat this Information Is correct and a Plot 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 Signature: WALTON ENGINEERING, INC. Technician I Cert M Jessie Wadkins I BM91 5307886 -UT Date: September 21, 2012 w zoiz wamm worm nno, ffm