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MONITORING SYSTEM CERTIFICATIO m - . MAKE / MODEL OF MONITORING SYSTEM: Veeder-Root TLS-350 AUG 10 2018 CERTIFICATION /TEST DATE: August 07, 2018 Al. FACILITY A2. OWNER Name Quik Stop Market#138 Name Quik Stop Markets, Inc.HEALTH DEPA9TMEN ,' Address 1153 Lincoln Blvd.,Tracy,CA 95376 Address 4567 Enterprise Street,Fremont,CA 94538 Phone# 510-657-8500 Phone# 510-657-8500 Contact Roger Batra Contact Debbie Markovich A3. C UP 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 25,2018 Lic# 617238 A,B,Haz Inspector Zuna 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) B1: TANKS Tank#1 (Product): Gasoline 87 Tank#2 (Product): Gasoline 89 ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: • Annular Space or Vault Sensor Model: 0794390.409 Annular Space or Vault Sensor Model: 0794390-409 • 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): Gasoline 91 Tank#4 (Product): _ ❑ In-Tank Gauging Probe Model: ❑ In-Tank Gauging Probe Model: 0 Annular Space or Vault Sensor Model: 0794390-409 ❑ Annular Space or Vault Sensor Model: E Piping Sump/Trench Sensor(s) Model: 0794380-208 ❑ Piping Sump/Trench Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: ❑ Fill Sump Sensor(s) Model: Mechanical Line Leak Detector Model: VMI 99LD-2000 ❑ 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 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 Q WALTON Signature: r/ � ENGINEERING,INC. Technician/Cert M Max Hines 849018/8760063 Date: August 7,2018 018 Walton Enginee ng,Inc.