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MONITORING SYSTEM CERTIFICATION <br /> MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root <br /> CERTIFICATION /TEST DATE: July 23, 2018 14nuEl d <br /> Al. FACILITY A2. OWNER JUL 2 7 2018 <br /> Name Quik Stop Market#144 Name Quik Stop Markets, Inc. <br /> Address 7272 West Lane,Stockton,CA 95210 Address 4567 Enterprise Street,Fremont,CA 94538 <br /> Phone# 510-657-8500 Phone# 510-657-8500ENVIRONMENTAL HEALTF <br /> Contact Roger Batra Contact Debbie Markovic <br /> A3. C UP A A4. TESTING CONTRACTOR <br /> Name San Joaquin County Environmental Health Name Walton Engineering,Inc. <br /> Address 1868 E.Hazelton Avenue,Stockton,CA 95202 Address P.O.Box 1025,W.Sacramento,CA 95691 <br /> Notified July 10,2018 Lic# 617238 A,B,Haz <br /> Inspector Stacy Rivera Contact Veronica Freitas <br /> Phone# 209-468-3442 Phone# 916-373-1166 <br /> B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) <br /> B1: TANKS <br /> Tank#1 (Product): 87 Tank#2 (Product): 89 <br /> ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: <br /> Annular Space or Vault Sensor Model: 0794390-409 Annular Space or Vault Sensor Model: 0794390-409 <br /> Piping Sump/Trench Sensor(s) Model: 0794380-208 Piping Sump/Trench Sensor(s) Model: 0794380.208 <br /> ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: <br /> Mechanical Line Leak Detector Model: VMI 99LD-2000 Mechanical Line Leak Detector Model: Red Jacket FX <br /> ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: <br /> ❑ Tank Overfill/High-Level Sensor Model: ❑ Tank Overfill/High-Level Sensor Model: <br /> ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: <br /> Tank#3 (Product): 91 Tank#4 (Product): _ <br /> ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: <br /> • Annular Space or Vault Sensor Model: 0794390-409 ❑ Annular Space or Vault Sensor Model: <br /> • Piping Sump/Trench Sensor(s) Model: 0794380-208 ❑ Piping Sump/Trench Sensor(s) Model: <br /> ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: <br /> 0 Mechanical Line Leak Detector Model: VMI 99LD-2000 ❑ Mechanical Line Leak Detector Model: <br /> ❑ Electronic Line Leak Detector Model: ❑ Electronic Line Leak Detector Model: <br /> ❑ Tank Overfill/High-Level Sensor Model: ❑ Tank Overfill/High-Level Sensor Model: <br /> ❑ Other (specify equipment in Section E) Model: ❑ Other (specify equipment in Section E) Model: <br /> B2: DISPENSERSWDC's <br /> Dispenser#: 1-2 Dispenser#: 3-4 <br /> 0 Dispenser Containment Sensor(s) Model: 0794380-208 0 Dispenser Containment Sensor(s) Model: 0794380-208 <br /> ❑ Shear Valves ❑ Shear Valves <br /> ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) <br /> Dispenser#: 5-6 Dispenser#: <br /> 0 Dispenser Containment Sensor(s) Model: 0794380-208 ❑ Dispenser Containment Sensor(s) Model: <br /> ❑ Shear Valves ❑ Shear Valves <br /> ❑ Dispenser Containment Float(s)and Chain(s) ❑ Dispenser Containment Float(s)and Chain(s) <br /> Dispenser#: Dispenser#: <br /> ❑ Dispenser Containment Sensor(s) Model: ❑ Dispenser Containment Sensor(s) Model: <br /> ❑ Shear Valves ❑ Shear Valves <br /> ❑ Dispenser Containment Float(s)and Chain(s) ❑ 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,1 have also attached a copy of the report; (check all that apply <br /> ❑ System set-up ❑ Alarm History Report <br /> v <br /> yam6 WALTON <br /> Signature: ENGINEERING,INC. <br /> Technician/Cert#: Nick Janoe B49017/8712764 Date: ,ILII),23,2018 <br /> 2018 Waltonngmeering, nM <br />