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MONITORING SYSTEM CERTIFICA i V GL'' MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION /TEST DATE: June 28, 2017 JUN 3 0 2017 A7. FACILITY A2. OWNER Name Quik Stop Market #148 Name Quik stop Mar VI1AQNMENTAL HEALT Address 205 W. Lockeford Street, Lodi, CA 95240 Address 4567 Enterprise Street, F@6F 1i T T Phone # 510-657-8500 Phone # 510-657-8500 Contact Roger Batra Contact Debbie Markovich A3. CUPA Name Name San Joaquin County Environmental Health Address 1868 E. Hazelton Avenue, Stockton, CA 95202 Notified June 14, 2017 Inspector Ellaina Phone # 209-468-3442 A4. TESTING CONTRACTOR Name Walton Engineering, Inc. Address P.O. Box 1025, W. Sacramento, CA 95691 Lic # 617238 A, B, Haz Contact Veronica Freitas Phone # 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) B1: TANKS Dispenser # : 1-2 ❑ Dispenser Containment Sensor(s) Model: Shear Valves Dispenser Containment Float(s) and Chain(s) Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser #: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) 132: DISPENSERS/UDC's Dispenser # : 3-4 ❑ Dispenser Containment Sensor(s) Model: Shear Valves Dispenser Containment Float(s) and Chain(s) Dispenser #: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) C. CERTIFICATION I 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: `- �' _ ENGINEERING. INC. Technician / Cert #: Curtis Carpenter / B37258 8020679 Date: Jude 18, 2017 Tank #1 (Product): Gasoline - 87 Tank #2 (Product): Gasoline -89 ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: • Annular Space or Vault Sensor Model: 0794390-409 i1♦ Annular Space or Vault Sensor Model: 0794390-409 • Piping Sump / Trench Sensor(s) Model: 0794380-208 i1♦ Piping Sump / Trench Sensor(s) Model: 0794380-208 ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: 0 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 #3 (Product): Gasoline - 91 Tank #4 (Product): ❑ 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: 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: Dispenser # : 1-2 ❑ Dispenser Containment Sensor(s) Model: Shear Valves Dispenser Containment Float(s) and Chain(s) Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser #: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) 132: DISPENSERS/UDC's Dispenser # : 3-4 ❑ Dispenser Containment Sensor(s) Model: Shear Valves Dispenser Containment Float(s) and Chain(s) Dispenser #: ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) C. CERTIFICATION I 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: `- �' _ ENGINEERING. INC. Technician / Cert #: Curtis Carpenter / B37258 8020679 Date: Jude 18, 2017