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MONITORING T CERTIFICATION AY 0 4 2016 MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350; �. CERTIFICATION /TEST DATE: April 18, 2016 �� . �1�-•: Al. FACILITY A2. OWNER Name Quik Stop Market #132 Name Quik Stop Markets, Inc. Address 3555 W. Hammer Lane, Stockton, CA 95219 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 Tank #2 (Product): Gasoline -89 A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Model: Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 Annular Space or Vault Sensor Address P.O. Box 1025, W. Sacramento, CA 95691 Notified April 6, 2016 ■ Lic # 617238 A, B, Haz Inspector Fatinah Zareet Model: 0794380-208 Contact Veronica Freitas Phone # 209-468-3442 Fill Sump Sensor(s) Phone # 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) B1: TANKS Tank #1 (Product): Gasoline - 87 Dispenser # : 3-4 Tank #2 (Product): Gasoline -89 Dispenser Containment Sensors) Model: 0794380-208 ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794390.409 ■ Annular Space or Vault Sensor Model: 0794390-409 ■ Piping Sump / Trench Sensor(s) Model: 0794380-208 ■ Piping Sump / Trench Sensor(s) Model: 0794380-208 ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ■ Mechanical Line Leak Detector Model: VMI 99LD-2000 Dispenser Containment Float(s) and Chain(s) 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: n., ❑ 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: FE Petro STP -MLD ❑ 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 Sensors) Model: 0794380-208 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Shear Valves Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # : 5-6 Dispenser#: 7-8 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ Dispenser Containment Sensor(s) Model: 0794380-208 ■ 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 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 E Alarm History Report t y ALTO Signature: W ENGINEERING, INC. Technician / Cert. M Jessie Wadkins / B35391 5307886 -UT Date: Aprd 18, 2016