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MONITORING SYSTEM CERTIFICATION <br />MAKE / MODEL OF MONITORING SYSTEM: Gilbarco EMC <br />CERTIFICATION/ TEST DATE: June 20, 2018 <br />Al. FACILITY A2. OWNER <br />Name Quik Stop Market #152 Name Quik Stop Markets, Inc. <br />Address 1721 S. Cherokee Lane #1, Lodi, CA 95240 Address 4567 Enterprise Street, Fremont, CA 94538 <br />Phone # 510-657-8500 Phone # 510-657-8500 <br />Contact Roger Batra Contact Debbie Markovich <br />A3. C U P A <br />Dispenser # : 1-2 <br />Dispenser # : 3-4 <br />A4. TESTING CONTRACTOR <br />Name <br />San Joaquin County Environmental Health <br />Name <br />Walton Engineering, Inc. <br />Address <br />1868 E. Hazelton Avenue, Stockton, CA 95202 <br />Address <br />P.O. Box 1025, W. Sacramento, CA 95691 <br />Notified <br />June 05, 2018 <br />Lic # <br />617238 A, B, Haz <br />Inspector <br />None <br />Contact <br />Veronica Freitas <br />Phone # <br />209-468-3442 <br />Phone # <br />916-373-1166 <br />❑ Shear Valves <br />❑ Shear Valves <br />B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) <br />❑ Dispenser Containment Float(s) and Chain(s) <br />B1: <br />TANKS <br />B2: DISPENSERS/UDC's <br />C. CERTIFICATION I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. <br />Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing th <br />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 <br />■ Svstem set-up ■ Alarm History Report <br />Signature: <br />WALTON <br />ENGINEERING, INC. <br />Technician / Cert #: Curtis Carpenter/ 837258 8020679 Date: ,June 20, 2018 <br />Dispenser # : 1-2 <br />Dispenser # : 3-4 <br />❑ Dispenser Containment Sensor(s) Model: <br />❑ Dispenser Containment Sensor(s) Model: <br />Shear Valves <br />Shear Valves <br />Dispenser Containment Float(s) and Chain(s) <br />Dispenser Containment Float(s) and Chain(s) <br />Dispenser # : <br />Dispenser # : <br />❑ Dispenser Containment Sensor(s) Model: <br />❑ Dispenser Containment Sensor(s) Model: <br />❑ Shear Valves <br />❑ Shear Valves <br />❑ Dispenser Containment Float(s) and Chain(s) <br />❑ Dispenser Containment Float(s) and Chain(s) <br />Dispenser # : <br />Dispenser # <br />❑ Dispenser Containment Sensor(s) Model: <br />❑ Dispenser Containment Sensor(s) Model: <br />❑ Shear Valves <br />❑ Shear Valves <br />❑ Dispenser Containment Float(s) and Chain(s) <br />❑ Dispenser Containment Float(s) and Chain(s) <br />C. CERTIFICATION I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. <br />Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing th <br />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 <br />■ Svstem set-up ■ Alarm History Report <br />Signature: <br />WALTON <br />ENGINEERING, INC. <br />Technician / Cert #: Curtis Carpenter/ 837258 8020679 Date: ,June 20, 2018 <br />