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t� f fi MONITORING SYSTEM CERTIFICAT MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 AUG 10 L017 CERTIFICATION /TEST DATE: August 8, 2017 Al. FACILITY A2. OWNER �tl�'d�! Name Quik Stop Market#39 Name Quik Stop Marke s,Inc r ,w Address 2285 E.Fremont Street,Stockton,CA 95205 Address 4567 Enterprise Street,Fremont CA 94538 Phone# 510-657-8500 Phone# 510-657-8500 Contact Roger Batra I Contact Debbie Markovich A3. C U P A A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Name Walton Engineering, Inc. Address 1868 E.Hazelton Avenue,Stockton,CA 95202 Address P.O.Box 1025,W.Sacramento,CA 95691 Notified July 27,2017 Lic# 617238 A,B,Haz Inspector Cesar Ruvalcaba Contact Veronica Freitas Phone# 209-468-3442 Phone# 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) 131: TANKS Tank#1 (Product): Gasoline-87 Tank#2 (Product): Gasoline-91 ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: Annular Space or Vault Sensor Model: 0794380-303 Annular Space or Vault Sensor Model: 0794380-303 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 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): Tank#4 (Product): _ ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: ❑ Piping Sump/Trench Sensor(s) Model: ❑ Piping Sump/Trench Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Mechanical Line Leak Detector Model: ❑ 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: 132: DISPENSERS/UDC's Dispenser#: 1-2 Dispenser#: 3-4 Dispenser Containment Sensor(s) Model: 0847990-001 Dispenser Containment Sensor(s) Model: 0847990-001 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) 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 ■ Alarm History Report LTON Signature: s7 �3� L�� rra 'NGINCERtNO,INC Technician/Cert#: Thomas Steiger A31060/8156310 Date: August 8,2017 ©2016 Walton Engineering,Inc.