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a • <br />MONITORING SYSTEM CERTIFICATION <br />CERTIFICATION / TEST DATE: September 21, 2012 <br />Al. FACILITY <br />A2. OWNER <br />Name Quik Stop Market 0148 <br />Name Oulk Stop Markets, Inc. <br />Address 205 W. Lockeford Street, Lodi, CA 95240 <br />Address 4567 Enterprise Street, Fremont, CA 94538 <br />Phone # 610-657-8500 <br />Phone # 510-657-8500 <br />Contact Michael Karvelot <br />Contact Michael Karvelot <br />F. IN -TANK GAUGING / SIR EQUIPMENT: ❑ Check this box H tank gauging is used only for inventory control. <br />❑ Check this box H no tank gauging or SIR equipment is Installed. <br />This section must be completed if in -tank gaugung equipment is used to perform leak detection monitoring. <br />Complete the following checklist: <br />�I <br />❑ Yes ❑ No' <br />Has all Input wiring been inspected for proper entry and termination, including testing for ground faults? <br />❑ Yes ❑ No <br />Were all tank gauging probes visually Inspected for damage and residue buildup? <br />❑ Yes ❑ No * <br />Was accuracy of system product level readings tested? <br />❑ Yes ❑ No <br />Was accuracy of system water level readings tested? <br />❑ Yes ❑ No • <br />Were all probes reinstalled properly? <br />Were all limns on the equipment manufacturers maintenance checklist completed? <br />❑ Yes ❑ No <br />" In Section H below, describe how and when these deficiencies were or will be corrected. <br />G. LINE LEAK DETECTORS (LLD): ❑ Check this box H LLDs are not Installed. <br />Complete the following checklist: <br />�I <br />■ Yes ❑ No For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? <br />❑ NIA (check all that apply) Simulated leak rate: ■ 3 g.p.h.; ❑ 0.1 g.p.h.; ❑ 0.2 g.p.h. <br />■ _Yes ❑ No' Were all LLDs confirmed operational and accurate within regulatory requirements? <br />j ■ Yes ❑ No • Was the testing apparatus properly calibrated? <br />■ Yes <br />❑ No' For mechanical LLDs, does the LLD restrict product flow H it detects a leak? <br />❑ NIA <br />❑ Yes <br />❑ No ` For electronic LLD9, does the turbine automatically shut off If the LLD detects a leak? <br />■ NIA <br />_. <br />❑ No " For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled <br />❑ Yes <br />■ WA or disconnected? <br />❑ No" For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions <br />❑ Yes <br />■ NIA or fails a test? <br />❑ Yes <br />❑ No • For electronic LLDs, have all accessible wiring connections been visually Inspected? <br />■ NIA <br />■ Yes <br />❑ No* Were all items on the equipment manufacturers maintenance checklist completed? <br />' In Section H below, describe how and when these deficiencies were or will be corrected. <br />H. COMMENTS <br />This is a test of the 91 MLLD. <br />® 2012 Walton eltgnneennS inc. <br />Page 3 of 3 <br />