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MONITORING SYSTEM CERTIFICATION MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS -350 CERTIFICATION /TEST DATE: Mav 3. 2017 A1. FACILITY A2. OWNER Name Quik Stop Market #120 Tank #1 (Product): Gasoline - 87 Name Quik Stop Markets, Inc. - Address 9321 Thornton Road, Stockton, CA 95209 In -Tank Gauging Probe Address 4567 Enterprise Street, Fremont, CA 94538 Phone # 510-657-8500 Phone # 510-657-8500 Contact Roger Batra Model: 0794380-301 Contact Debbie Markovich Model: 0794380-208 Dispenser Containment Sensor(s) Model: Piping Sump / Trench Sensor(s) Model: 0794380-208 ❑ A3. C UP A Model: ❑ A4. TESTING CONTRACTOR Name San Joaquin County Environmental Health Mechanical Line Leak Detector Name Walton Engineering, Inc. Address 1868 E. Hazelton Avenue, Stockton, CA 95202 ❑ Address P.O. Box 1025, W. Sacramento, CA 95691 Notified April 21, 2017 Model: Lic # 617238 A, B, Haz Inspector Cesar Ruvalcabra Tank Overfill / High -Level Sensor 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) Tank #3 (Product): 131: TANKS 1a011111111r)F9»►6y4:R301view Dispenser # : 1-2 Dispenser # : 3-4 Tank #1 (Product): Gasoline - 87 Dispenser Containment Sensor(s) Model: Tank #2 (Product): Gasoline - 91 Dispenser Containment Sensor(s) Model: ❑ In -Tank Gauging Probe Model: ❑ In -Tank Gauging Probe Model: Annular Space or Vault Sensor Model: 0794380-301 Annular Space or Vault Sensor Model: 0794380-301 Dispenser # : Piping Sump / Trench Sensor(s) Model: 0794380-208 Dispenser Containment Sensor(s) Model: 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 0 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: 1a011111111r)F9»►6y4:R301view C. CERTIFICATION 1 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 /} ,;fALTON (/ tl Signature: . /i� ENGINEERING, INC. Technician / Cert M Anthony Reyes B45115 8293772 Date: May 3, 2017 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 1 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 /} ,;fALTON (/ tl Signature: . /i� ENGINEERING, INC. Technician / Cert M Anthony Reyes B45115 8293772 Date: May 3, 2017