COMPLIANCE INFO_2013-2018 DOUBLE CHECK

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MONITOWING SYSTEM CERTIM�ATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION /TEST DATE: Mav 3. 2013 Al. FACILITY A2. OWNER 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 Michael Karvelot Contact Michael Karvelot A3. C U P A ❑ A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Annular Space or Vault Sensor Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 ❑ Address P.O. Box 1025, W. Sacramento, CA 95691 Notified April 18, 2013 Model: VMI 99LD-2000 Lic # 617238 A, B, Haz Inspector Garret Backus Tank Overfill/ High -Level Sensor Contact Dulcinea Covan Phone # 209-468-8257 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 ❑ In -Tank Gauging Probe Model: ■ Annular Space or Vault Sensor Model: 0794380-301 ■ Piping Sump / Trench Sensor(s) Model: 0794380-208 ❑ Fill Sump Sensor(s) Model: ■ Mechanical Line Leak Detector Model: VMI 99LD-2000 ❑ Electronic Line Leak Detector Model: ❑ Tank Overfill/ High -Level Sensor Model: ❑ Other (specify equipment in Section E) Model: Tank #3 (Product): ❑ In -Tank Gauging Probe ❑ Annular Space or Vault Sensor ❑ Piping Sump / Trench Sensor(s) ❑ Fill Sump Sensor(s) ❑ Mechanical Line Leak Detector ❑ Electronic Line Leak Detector ❑ Tank Overfill / High -Level Sensor ❑ Other (specify equipment in Section E) Model: Model: Model: Model: Model: Model: Model: Model: Tank #2 (Product): Gasoline - 91 ❑ In -Tank Gauging Probe ■ Annular Space or Vault Sensor ■ Piping Sump / Trench Sensor(s) ❑ Fill Sump Sensor(s) ■ Mechanical Line Leak Detector ❑ Electronic Line Leak Detector ❑ Tank Overfill / High -Level Sensor ❑ Other (specify equipment in Section E) Tank #4 (Product): ❑ In -Tank Gauging Probe ❑ Annular Space or Vault Sensor ❑ Piping Sump / Trench Sensor(s) ❑ Fill Sump Sensor(s) ❑ Mechanical Line Leak Detector ❑ Electronic Line Leak Detector ❑ Tank Overfill / High -Level Sensor ❑ Other (specify equipment in Section E) i :� •� l.�» I; iy � :�.yu � •ice Model: Model: 0794380-301 Model: 0794380-208 Model: Model: VMI 99LD-2000 Model: Model: Model: Model: Model: Model: Model: Model: Model: Model: Model: 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: ENGINEERING, INC. Technician / Cert #: Curtis Carpenter / B37258 8020679 Date: May 3, 2013 Dispenser # : 1-2 ❑ Dispenser Containment Sensor(s) Model: ■ Shear Valves ■ Dispenser Containment Float(s) and Chain(s) Dispenser ❑ ■ ■ # : 3-4 Dispenser Containment Sensor(s) Model: Shear Valves Dispenser Containment Float(s) and Chain(s) Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser ❑ ❑ ❑ # Dispenser Containment Sensor(s) Model: Shear Valves Dispenser Containment Float(s) and Chain(s) Dispenser # : ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ Dispenser Containment Float(s) and Chain(s) Dispenser # ❑ Dispenser Containment Sensor(s) Model: ❑ Shear Valves ❑ 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: ENGINEERING, INC. Technician / Cert #: Curtis Carpenter / B37258 8020679 Date: May 3, 2013