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v Alltech 17759 Buttercup Circle, Sonora, CA 95370 Phone: 209-532-7320; Fax: 209-533-2650 California Contractor 623541 A-Haz Mike@MtechPetro.com Fj% MONITORING SYSTEM CERTIFICATION A. General Information Facility Name: Costco# 658 Tracy Date of Testing/Servicing: September 1, 2004 Facility Address:3250 W. Grant Line Rd., Tracy CA 95304 Facility Contact Person: Leo Facility Phone: 209-834-1247 LIA: San Joaquin Health; Inspector: Steven Shih; LIA Phone: (209) 468-9850; LIA Fax: (209) 468-3433 Make/Model of Monitoring System: Veeder-Root TLS-350 B. Inventory of Equipment Tested/Certified: Tank ID:Regular 1 Tank Tank ID: Regular 2 Tank ®In-Tank Gauging Probe. Model:Mag 1 0 in-Tank Gauging Probe. Model:Mag 1 •Annular Space or Vault Sensor. Model:Single-Float Brine 0 Annular Space or Vault Sensor. Model:Single-Float Brine ®Piping Sump Sensor(s). Model:Discriminating Sensor ®Piping Sump Sensor(s). Model:Discriminating Sensor ®Fill Sump Sensor(s). Model:Discriminating Sensor JZ Fill Sump Sensor(s). Model:Discriminating Sensor ®Mechanical Line Leak Detector. Model:Vaproless ®Mechanical Line Leak Detector. Model:Vaporless ❑Electronic Line Leak Detector_ Model: ❑Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: ®Tank Overfill/High-Level Sensor. Model:Veeder-Boot Audible ❑Fillspill Bucket Tested: ®Pass []Fail E Fillspill Bucket Tested: ®Pass ❑Fail Other Fireextin guiskiers checked and to ed Other Fire a ishesr checked and to ed Tank ID:Premium Tank; Capacity: Tank ID:None ®In-Tank Gauging Probe. Model Mag 1 ❑In-Tank Gauging Probe. Model: •Annular Space or Vault Sensor. Model:Single-Float Brine ❑Annular Space or Vault Sensor. Model: •Piping Sump Sensor(s). Model:Discriminating Sensor ❑Piping Sump Sensor(s). Model: ®Fill Sump Sensor(s). Model:Discriminating Sensor ❑Fill Sump Sensor(s). Model: •Mechanical Line Leak Detector. Model:Vaporless ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model:Veeder-Boot Audible ❑Tank Overfill/High-Level Sensor. Model: ®Fillspill Bucket Teste&: ®Pass ❑Fail ❑ 1'illspill Bucket Tested: ❑Pass []]Fail ®Other Fire extinguishers checked and tagged ❑Other Fire etititi uisher,checked and ed Dispenser ID: 1&2 0 Sump:®Dry❑Water❑Product Dispenser ID:3&4®Sump: ®Dry❑Water❑Product •Dispenser Containment Sensor(s). Model:Non-Discriminating ®Dispenser Containment Sensor(s). Model:Non-Discriminating ®Shear Valve(s) (Functional test) ®Shear Valve(s) (Functional test) •Fire ektnguisher checked and tagged ®Fire extin uisher checked and to ed Dispenser 1D: 5&6 l�j Sump:®Dry[]Water❑Product Dispenser ID: 7&8 M Sump: ❑Dry❑Water[]Product ®Dispenser Containment Sensor(s). Model:Non-Discriminating 0 Dispenser Containment Sensor(s). Model:Non-Discriminating ®Shear Valve(s) (Functional test) ®Shear Valve(s) (Functional test) ®Fire extinguisher checked and tagged ®Fire extinguisher checked and tagged Dispenser ID: 9&10®Sump: ®Dry❑Water❑Product Dispenser ID: 11&12® Sump: ®Dry❑Water❑Product ®Dispenser Containment Sensor(s). Model:Non-Discriminating ®Dispenser Containment Sensor(s). Model:Non-Discriminating ®Shear Valve(s) (Functional test) Shear Valve(s) (Functional test) 0 Fire extinguisher checked and tagged Fire extin uisher checked and tagged Dispenser ID: 13&14®Sump: ®Dry❑Water❑Product Dispenser ID: 15& 16❑Sump: ®Dry❑Water❑Product ®Dispenser Containment Sensor(s). Model:Non-Discriminating ®Dispenser Containment Sensor(s). Model:Non-Discriminating ®Shear Valve(s) (Functional test) ®Shear Valve(s) (Functional test) ❑Fire extinguisher checked and aed ❑Fire extin 'sher checked and tagged C. Certification-l certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers'guldetines. Attached to this Certification is a Piot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,l hatic also attached a copy of the report; ®System set-up N Alarm history repos! Technician: Mike Dotten,California Contractor 623541 A-Haz Certification:Veeder-Root: 006-05-0789;Level 4.