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0 <br /> J ,�% P.O.Box 4208 <br /> Alltechfttr V ' Sonora 370 <br /> Ca:623541 A-Haz <br /> Phone:209-5353 2-7-7320 <br /> Compliance without Compromise Fax:209-533-2650 <br /> mail@alltechpetro.com <br /> MONITORING SYSTEM CERTIFICATION www.alltechpetro.com <br /> A. General Information <br /> Facility Name: Costco # 038 Stockton Date of Testing/Servicing: June 10, 2013 <br /> Facility Address:1616 W. Hammer Lane, Stockton CA <br /> Facility Contact Person: Rick Medeiros (Ser. Sta. Supervisor); Facility Phone: (209) 478-2040 <br /> LIA: San Joaquin Health; Inspector: Jeff Wong; LIA Phone: (209) 468-3448; LIA Fax: <br /> Make/Model of Monitoring System: Veeder-Root TLS-350 <br /> B. Inventory of Equipment Tested/Certified: <br /> Tank ID: Unleaded 87A Tank 1 Tank ID: Unleaded 87B Tank 2 <br /> ®In-Tank Gauging Probe. Model: Mag 1 Nin-Tank Gauging Probe. Model: Mag 1 <br /> NTank Annular Space Sensor. Model: 794380-301 ®Tank Annular Space Sensor. Model: 794380-301 <br /> NPiping Sump Sensor(s). Model: 857080-112 NPiping Sump Sensor(s). Model: 857080-112 <br /> NFill Sump Sensor(s). Model: 794380-323 NFill Sump Sensor(s). Model: 794380-323 <br /> NFill Sump Annular Sensor. Model: 794380-304 NFill Sump Annular Sensor. Model: 794380-304 <br /> NElectronic Line Leak Detector. Model: PLLD NElectronic Line Leak Detector. Model: PLLD <br /> NTank Overfill/High-Level Sensor. Model:V-R Audible NTank Overfill/High-Level Sensor. Model: V-R Audible <br /> ❑ Fillspill Bucket Tested: ❑Pass ❑Fail ❑ Fillspill Bucket Tested: ❑Pass []Fail <br /> N Fire extinguishers inspected and tagged: NOK []NotOK N Fire extinguishers inspected and to ed: NOK❑Not OK <br /> Tank ID: Unleaded 91 Tank 3 Tank ID: Fuel Additive Tank 4 <br /> N In-Tank Gauging Probe. Model: Mag 1 Nln-Tank Gauging Probe. Model: Mag 1 <br /> NAnnuldr Space Sensor. Model: 794380-301 NTank Annular Space Sensor. Model: 794380-302 <br /> NPiping Sump Sensor(s). Model: 857080-112 NPiping/Fill Sump Sensor(s). Model: 794380-323 <br /> N Fill Sump Sensor(s). Model: 794380-323 NPiping/Fill Sump Annular Sensor. Model: 794380-304 <br /> NFill Sump Annular Sensor. Model: 794380-304 NMechanical Line Leak Detector. Model: Fe Petro <br /> NElectronic Line Leak Detector. Model: PLLD NTank Overfill/High-Level Sensor. Model:V-R Audible <br /> NTank Overfill/High-Level Sensor. Model:V-R Audible N Fillspill Bucket Tested: NPass []Fail <br /> ❑ Fillspill Bucket Tested: ❑Pass ❑Fail N Fire extinguishers inspected and tagged: NOK ❑Not OK <br /> N Fire extinguishers inspected and tagged: NOK []Not OK <br /> Dispenser ID: 1&2 N Sump: NDry❑Water❑Product Dispenser ID: 3&4 N Sump: NDry❑Water❑Product <br /> NDispenser Containment Sensor(s). Model: 794380-208 NDispenser Containment Sensor(s). Model: 794380-208 <br /> NShear Valve(s) (Functional test) NShear Valve(s) (Functional test) <br /> N Fire extinguisher inspected and tagged: NOK ❑Not OK N Fire extinguisher inspected and tagged: NOK ❑Not OK <br /> Dispenser ID: 5&6 N Sump: NDry[]Water❑Product Dispenser ID: 7&8 N Sump: NDry❑Water❑Product <br /> NDispenser Containment Sensor(s). Model: 794380-208 NDispenser Containment Sensor(s). Model:794380-208 <br /> NShear Valve(s) (Functional test) NShear Valve(s) (Functional test) <br /> N Fire extinguisher inspected and to ed: NOK ❑Not OK N Fire extinguisher inspected and tagged: NOK ❑Not OK <br /> Dispenser ID: 9&10 N Sump: NDry❑Water❑Product Dispenser ID: 11&12 N Sump: NDry❑Water❑Product <br /> NDispenser Containment Sensor(s). Model: 794380-208 NDispenser Containment Sensor(s). Model: 794380-208 <br /> NShear Valve(s) (Functional test) NShear Valve(s) (Functional test) <br /> N Fire extinguisher inspected and tagged: NOK ❑Nat OK N Fire extinguisher inspected and tagged: NOK []Not OK <br /> Dispenser ID:Vent Stack N Sump:NDry❑Water❑Product Dispenser ID:Adtiv Vent N Sump:NDry❑Water❑Product <br /> NSump Containment Sensor(s). Model: 794380-323 NSump Containment Sensor(s). Model: 794380-323 <br /> NSump Annular Sensor(s). Model:794380-304 N Sump Annular Sensor(s). Model: 794380-304 <br /> N Fire extinguisher inspected and tagged: NOK ❑Not OK N Fire extinguisher inspected and tagged: NOK ❑Not OK <br /> C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' <br /> guidelines. Attached to this Certification is a Plot Plan showing the layout of monitoring equipment. For any equipment capable of <br /> generating such reports,I have also attached a copy of the report; ®System set-up ®Alarm history report <br /> Technician: RECEIVED Date: 06/10/13 <br /> Certification: Veeder-Root 636878, Level 4 JUN 2 4 2013 <br /> ICC UST Service Technician # 8146912-UT SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />