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i Allteeh 17759 Buttercup Circle, Sonora, CA 95370 Phone: 209-532-7320; l''ax: 209-533-2650 California Contractor 623541 A-Haz alltech@getrocket_com I j MONITORING SYSTEM CERTIFICATION A. General Information Facility Name: Costco # 658 Tracy Date of Testing/Servicing: September 16, 2003 Facility Address: 3250 W. Grant Line Road, Tracy CA Facility Contact Person: Ser. Sts. Supervisor; Leo LIA: San Joaquin; Steven LIA Phone: Make/Model of Monitoring System: Veeder-Root TLS-350 B. Inventory of Equipment Tested/Certified: Check[Elle appropriate boxes to indicate specific equipment ment ins ctedlsen,iced: Tank ID:Regular 1 Tank Tank ID:Regular 2 Tank ®In-Tank Gauging Probe. Model:Mag 1 ®In-Tank Gauging Probe. Model:Mag ®Annular Space or Vault Sensor. Model:Single-Float Brine ®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 N Fill Sump Sensor(s). Model:Discriminating Sensor ®Mechanical Line Leak Detector. Model:Red Jacket N Mechanical Line Leak Detector. Model:Red Jacket ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model:Veeder-Root Audible ®Tank Overfill/High-Level Sensor. Model:Veeder-Root Audible ❑Other ❑Other Tank ID:Premium Tank Tank ID: ®In-Tank Gauging Probe. Model:Mag I ❑In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model:Single-Float Brine ❑Annular Space or Vault Sensor. Model: 23 Piping Sump Sensor(s). Model:Discriminating Sensor ❑Piping Sump Sensor(s). Model: IQ Fill Sump Scnsor(s). Model:Discriminating Sensor ❑Fill Sump Sensor(s). Model: 13 Mechanical Line Leak Detector. Model:Vaporless L]Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model:Veeder-Root Audible ❑Tank Overfill/High-Level Sensor. Model: ❑Other ❑Other Dispenser ID: 1&2 Z Sump:EDry❑Water❑Product Dispenser ID:3&4® Sump:(DDry❑Water❑Product ®Dispenser Containment Sensor(s). Model:Non-Discriminating ®Dispenser Containment Sensor(s). Model:Non-Discriminating Shear Valve(s) (Functional test) E Shear Valve(s) (Functional test) ❑ Dispenser Containment Floats and Chain(s). ❑Dispenser Containment Float(s)and Chains . Dispenser ID:5&6® Sump:®Dry❑Water[]Product Dispenser ID: 7&8® Sump:EDry❑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) ❑Dispenser Containment Floats and Chain(s). ❑Dispenser Containment Floats and Chain(s). Dispenser ID:9&10 0 Sump:®Dry❑Water❑Product Dispenser ID: 11&12 2 Sump:JZDry❑Water❑Product ®Dispenser Containment Sensor(s). Model:Non-Discriminating ®Dispenser Containment Sensor(s). Model:Non-Discriminating N Shear Valve(s) (Functional test) 0 Shear Valve(s) (Functional test) ❑Dispenser Containment Float(s)and Chain(s). ❑DiseEnser Containment Floai(s)and Chain(s). Dispenser 1D: ❑ Sump:F-1 Dry❑Water❑Prod uct Dispenser ID: ❑ Sump:El Dry❑Water❑Product ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s) (Functional test) ❑Shear Valve(s) (Functional test) ❑Dispenser Containment Float(s)and Chain(s)_ ❑Dis enser 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 the layout of monitoring equipment. For any equipment capable of generating such reports,1 have also attached a copy of the report; (check all that apply): ER System set-up M Alarm history report Technician: /'KW i9we"r Mils Dotten,California Contractor 623541 A-Haz Certification: Veeder-Root:341-32-6743; Level 3.