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MONITORING SYSTEM CERTIFICATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION / TEST DATE: July 5, 2016 Al. 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 # 510-657-8500 Contact Roger Batra Contact Debbie Markovich A3. C U P A Dispenser # : 3-4 A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Tank #1 (Product): Gasoline - 87 Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 In -Tank Gauging Probe Address P.O. Box 1025, W. Sacramento, CA 95691 Notified June 22, 2016 • Lic # 617238 A, B, Haz Inspector Fatinah Zareef Model: 0794390-409 Contact Veronica Freitas Phone # 209-468-3442 Piping Sump / Trench Sensor(s) Phone # 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) B1: TANKS B2: DISPENSERS/UDC's Dispenser #: 1-2 Dispenser # : 3-4 ❑ Dispenser Containment Sensor(s) Model: Tank #1 (Product): Gasoline - 87 Dispenser Containment Sensor(s) Model: Tank #2 (Product): Gasoline -89 Shear Valves ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: • Annular Space or Vault Sensor Model: 0794390-409 M Annular Space or Vault Sensor Model: 0794390-409 • Piping Sump / Trench Sensor(s) Model: 0794380-208 E Piping Sump / Trench Sensor(s) Model: 0794380-208 ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: E Mechanical Line Leak Detector Model: Red Jacket FX 0 Mechanical Line Leak Detector Model: VMI 99LD-2000 ❑ 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: Tank #4 (Product): _ Tank #3 (Product): Gasoline - 91 ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: • Annular Space or Vault Sensor Model: 0794390-409 ❑ Annular Space or Vault Sensor Model: • Piping Sump / Trench Sensor(s) Model: 0794380-208 ❑ Piping Sump / Trench Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: 0 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 Dispenser #: 1-2 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 # : ❑ 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 # : ❑ 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) C. CERTIFICATION 1 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 History Report �- WALTON Signature: r�,G ° I �� a ENGINEERING, INC. Technician / Cert M Anthony Reyes B46115 8293772 Date: July 5, 2016