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MONITORING SYSTEM CERTIFIC CERTIFICATION/ TEST DATE: June 28, 2017 AN 3 0 2017 Al. FACILITY A2. OWNER EIF�ONiV1ENTALiEALTH Name Quik Stop Market #748 Name Quik Stop Mare , c ��-� Address 205 W. Lockeford Street, Lodi, CA 95240 Address 4567 Enterprise Street,cirit, CA� Phone # 510-657-8500 Phone # 510-657-8500 Contact Roger Batra contact Debbie Markovich F. IN -TANK GAUGING / SIR EQUIPMENT: ■ Check this box if tank gauging is used only for inventory control. ❑ Check this box if no tank gauging or SIR equipment is installed. This section must be completed if in -tank gaugung equipment is used to perform leak detection monitoring. Complete the following checklist: ❑ Yes ❑ No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults? ❑ Yes ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup? ❑ Yes ❑ No* Was accuracy of system product level readings tested? ❑ Yes ❑ No* Was accuracy of system water level readings tested? ❑ ❑ Yes Yes ❑ 1 ❑ No* No* Were all probes reinstalled properly? Were all items on the equipment manufacturer's maintenance checklist completed? * In Section H below, describe how and when these deficiencies were or will be corrected. G. LINE LEAK DETECTORS (LLD): Complete the following checklist: ❑ Check this box if LLDs are not installed. ■ Yes ❑ No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? ❑ N/A (check all that apply) Simulated leak rate: ■ 3 g.p.h.; ❑ 0.1 g.p.h.; ❑ 0.2 g.p.h. ■ Yes ❑ No* Were all LLDs confirmed operational and accurate within regulatory requirements? ■ Yes ❑ No* Was the testing apparatus properly calibrated? ■ Yes ❑ No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak? ❑ N/A ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? ■ N/A ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled ■ N/A or disconnected? ❑ Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions ■ N/A or fails a test? ❑ Yes ❑ No* For electronic LLDs, have all accessible wiring connections been visually inspected? ■ N/A ■ Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? * In Section H below, describe how and when these deficiencies were or will be corrected. H. COMMENTS Page 3 of 3