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MONIT4WING SYSTEM CERT1WoAT10 L MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 CERTIFICATION /TEST DATE: Mav 6, 2015 MAY 11 2015 A1. FACILITY INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) A2. OWNER - I . TA 3 Name Quik Stop Market #120 Name Quik Stop Markets, Inc. Address 9321 Thornton Road, Stockton, CA 95209 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 INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) 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 April 21, 2015 Lic # 617238 A, B, Haz Inspector Stacy Rivera ❑ Contact Veronica Freitas Phone # 209-468-8257 In -Tank Gauging Probe Phone # 916-373-1166 B. INVENTORY OF EQUIPMENT TESTED/CERTIFIED (Check the appropriate boxes to indicate equipment inspected/serviced) B1: TANKS Tank #1 (Product): Gasline-87 Tank #2 (Product): Gasoline -91 ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794380301 ■ Annular Space or Vault Sensor Model: 0794380301 ■ 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: V_MI 99L_D-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: 62: DISPENSERS/UDC's Dispenser # : 1-2 Dispenser # : 3-4 ❑ 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) 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 the 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 WALTON Signature: 4��6 7,� ENGINEERING, INC. Technician / Cert M Thomas Steiger A31060 / 8156310 Date: May 6, 2015