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Sep 24 05 10: 50p Mike Dotten (2091 533 -2650 p• 1 v 17759 Buttercup Circle, Sonora, CA 35370 �1 Phone: 209-532-7320; Fax: 209-533-2650 1 California Contractor 623541 A-Haz Mike@AlltcchPetro.com MONITORING SYSTEM CERTIFICATION A. General Information Facility Name: Costco# 658 Tracy Date of Testing/Servicirtg: September 7, 2005 Facility Address: 3250 W. Grant Line Road,Tracy CA 95304 Service Station Supervisor: Robert Mendoza Hut Phone: 834-1247 Warehouse Phone: (209) 830-5343 LIA: San Joaquin Health;Inspector: Willy Ng; LIA Phone: (209) 468.3448; LIA Fax. (209)468-3433 Make/Mode] of N4oni*orinZ 5-vstem: Veeder-Root TLS-350 B. Inventory ofEquipment Tested/Certified: Tank ID:Regular I Tank Tank iD R"onlor 2 Tank M IN Ili-:un#4 ir,Tu nic 'robs. �%lo:et:Mag I SSI In-1 ank Gauging Probe. dude]:Niag I ®Anr alar Space Scnsor. Model:Single-Ptoat Brine M Annular Space Sensor. Model:SinrJe-Float i3rine Piping Sump Sensor(s). Model:Discriminating Sensor M Piping Sump Sensor(s). Modal:Discriminating Sensor ®Fill Sump Sensor(s). Model:Discriminating Sensor M Fill Sump Sensor(s). Model:Discriminating Scnsor ®Mechanical Line Leak Detector. Model:Vaporless ®Mechanical].ane Leak Detector. Model:Vaporlam M Tank Overfill/High-Level Sensor. Model:V-R Audible 0 Tank Ovcrftll I Iligh-Level Sensor. Model:V-R Audible ®Fillspill Bucket Tested: Pass ❑hail M Fillspill Bucket Tasted: ®Pass ❑Fail ® Fire extinguishers inspected and to ed: NOK ONot OK_ 9_Fire extinguishers inspected and tagged: OOK ❑Not OK Tank ID:Premium Tank: -rank ID:None M In-Tank Gauging Probe. Model:Mag I El In-Tank Gauging Probe. Model: M Annular Space Serisor. Model:Single-Float 13rine ❑Annular Space Sensor. Model: 0 Piping Sump Sensor(s). Model:Discriminating Sensor ❑Piping Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model:Discriminating Sensor ❑Fill Sump Sensor(s). Model: N Mechanical bine Leak Detector. Model:iced Jacket ❑ fine Leak:Detector. Model: M Tank Overfill/High-Level Sensor. Model:V-R Audible El Tank Overfill/High-Level Sensor. Model: a Fillspill Bucket Tested: OPass Ell-'ail ❑Fillspill Bucket Tested: ❑Pass ❑Fail ® Fire extinguishers ins22cred and t e . MOK Not OK ❑ Fire extin ishcrs ins ectcd and tagged: ❑OK ❑Nol OK Dispenser ID: I&2 M Sump:®Dry❑Water[I Product Dispenser ID:3&4 M Sump:®Dry❑Water El Product M Dispenser Containment Sensor(s). Model:Non-Discriminating ®Dispenser Containment Scnsor(s). ;Model:Non-Discriminating M Shear Valve(s) (Functional test) M Shear Vaive(s) (Functional test) M Fire extinguisher inspected and ed: ®OK ❑Not OK M Fire extinguisher inspected and taped: ®OK ❑Not OK Dispenser ID:5&6 M Sump;ODry❑XVater❑Product Dispenser ID: 7&8 M Sump:MDry❑Water❑Product ®Dispenser Cuutainment Sensor(s). Model.Non-Discriminating ®Dispenser Containment Sensor(s). i'vtodel:Non-Discriminating ®Shear Valve(s) (Functional test) M Shear Valves) (Functional teat) li M Fire ext9nauishcr insrer:ted and taeeed MOK ❑Nos OK 1RI i-irc exiin5micher inspected and, ged: 1,5t OK ❑Nnt OK Dispenser ID:9&10 M Sump:®Dry i❑Water❑Products i Dispenser ID: I I&12® Sump:Of ❑1N'ater❑Produce W Disprmcr CUtlLai nn1CJII !u,r!.�J. Fvl�xial:tion-I}iscriminuling II L�j Dislxm;er COnlainnlent Scnsur(s). Model:tion-Dis+.-rintinating M Sbmr Vnkc(c) TunC iCMIl tccti fl M Shear Vatve(s) (Functional test) M lire extin11isher ins ecled and to ted: 20K ❑Not OK M t'ire extin wisher insnecled and t s+ed: MOK ❑Not OK Dispenser 1D.- ❑ Sump:❑LTy j�J.acr _iroduci Dispenser ID: ❑ Stunp:❑Dry iat.r - i_jPruduct ❑E)ir; n,rr Cunt 1 nmLmi Srnso(,,. 1ta d.1: & ❑D�Spc ?ger�'nmtaitltt}ent GCn,ur(a). ltodrl: ❑Shear'Vattc(s) (FUnctulnal tc l) ❑Shear'vai+els) d unctional test) l-s Firc,c tarsuishcr inspcc.ted .ltd t e.I ❑U:ti ❑Nut Usti ❑ Firc_.linens her inspeci d and gado ❑J� j]Nol OK [:. {;ertitTtatiaa- i cc;'tih-the t ihz:cF;:.:;:.nen.:.1_ett.i._:t tst tt!i,t1t~ct;r.:2at vvs+;sa�.;scetetF:tc:'tztii i9�^t>:.+..c4 to this Cetlil ca .:0 i a P.ot Nan .circ t c;..�011t nFrar..itrwiil-e.uipaicai. ;7:.f r.Fly,y ju;gym.nt tiapahtr O +.r. At Alco a::rhed a copy of the report; O S�ystjem set/-ap Alarm history report / h-y TPCiI T}FCi:i i:: =.:_w_. n •- l.ileii:'aC6'�s5a.1 .-j-c-i�{3J ifii Certification: Veeder-Root: 006-05-0789.Level 4. ;ICC UST Service Technician A 5259412-UT.