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MONITORING YTCERTIFICATION <br /> MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 <br /> CERTIFICATION/TEST DATE: May 02, 2018 <br /> Al. FACILITY A2. OWNER <br /> Name Quik Stop Market#120 Name Quik Stop Markets,Inc. <br /> Address 9321 Thornton Road,Stockton,CA 95209 Address 4567 Enterprise Street,Fremont,CA 94538 <br /> Phone# 510-657-8500 Phone# 510-657-8500 <br /> Contact Roger Batra Contact Debbie Markovich <br /> A3. C U P 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 April 18,2018 Lic# 617238 A,B,Haz <br /> Inspector Alan Hang 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): Gasoline-87 Tank#2 (Product): Gasoline-91 <br /> ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: <br /> Annular Space or Vault Sensor Model: 0794380-301 ® Annular Space or Vault Sensor Model: 0794380-301 <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 N Mechanical Line Leak Detector Model: VMI 99LD-2000 <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): Tank#4 (Product): <br /> ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: <br /> ❑ Annular Space or Vault Sensor Model: ❑ Annular Space or Vault Sensor Model: <br /> ❑ Piping Sump/Trench Sensor(s) Model: ❑ Piping Sump/Trench Sensor(s) Model: <br /> ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: <br /> ❑ Mechanical Line Leak Detector Model ❑ 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: DISPENSERS/UDC's <br /> Dispenser#: 1-2 Dispenser#: 3-4 <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 /> 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 /> 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,I have also attached a copy of the report; (check all that apply <br /> ■ System set-up 0 Alarm History Report <br /> aasota <br /> Signature: GMEERING,JNC. <br /> Technician/Cert M Anthony Reyes 845115 8293772 Date: May 2, 2018 <br /> ©1519 Walton Engineering,Inc. <br />