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P.O.Box 4208 AlltechfttrchSonora 53 -7370 Ca:623541 A-Haz Phone:209-532-7320 Compliance without Compromise Fax:209-533-2650 ma ilga I(tech petm.com www.a I(tech petro.com MONITORING SYSTEM CERTIFICATION A. General Information Facility Name: Costco # 038 Stockton Date of Testing/Servicing: March 8, 2012 Facility Address:1616 W. Hammer Lane, Stockton CA Facility Contact Person: Rick Medeiros (Ser. Sta. Supervisor); Facility Phone: (209) 478-2040 LIA: San Joaquon Health; Inspector: Garrett Backus; LIA Phone: (209) 468-3448; LIA Fax: Make/Model of Monitoring System: Veeder-Root TLS-350 B. Inventory of E ui ment Tested/Certified: Tank ID: Regular 1 Tank Tank ID: Regular 2 Tank ®In-Tank Gauging Probe. Model: Mag 1 EIn-Tank Gauging Probe. Model: Mag 1 ❑Annular Space Sensor. Model:794380-301 EAnnular Space Sensor. Model: 794380.301 N Piping Sump Sensor(s). Model:857080-112 EPiping Sump Sensor(s). Model:857080-112 E Fill Sump Sensor(s). Model:794380-352 EFill Sump Sensor(s). Model:857080.112 N Electronic Line Leak Detector. Model: PLLD EElectronic Line Leak Detector. Model: PLLD ❑Tank Overfill/High-Level Sensor. Model:V-R Audible NTank Overfill/High-Level Sensor. Model:V-R Audible N Fillspill Bucket Tested: EPdss ❑Fail E Fillspill Bucket Tested: NPass ❑Fail N Fire extinguishers inspected and tagged: NOK E]Not OK N Fire extinguishers inspected and tagged: NOK❑Not OK Tank ID: Premium Tank: Tank ID: None N In-Tank Gauging Probe. Model: Mag 1 El In-Tank Gauging Probe. Model: EAnnular Space Sensor. Model:794380.301 ❑Annular Space Sensor. Model: EPiping Sump Sensor(s). Model:857080-112 ❑Piping Sump Sensor(s). Model: E Fill Sump Sensor(s). Model:857080-112 ❑Fill Sump Sensor(s). Model: EElectronic Line Leak Detector. Model: PLLD ❑ Line Leak Detector. Model: ETank Overfill/High-Level Sensor. Model:V-R Audible ❑Tank Overfill/High-Level Sensor. Model: E Fillspill Bucket Tested: NPass ❑Fail E] Fillspill Bucket Tested: ❑Pass —]Fail E Fire extinguishers inspected and tagged: EOK ❑Not OK ❑ Fire extinguishers inspected and tagged: ❑OK ❑Not OK Dispenser ID: 1&2 N Sump: EDry❑Water❑Product Dispenser ID: 3&4 N Sump: EDry❑Water❑Product N Dispenser Containment Sensor(s). Model: 794380-208 E Dispenser Containment Sensor(s). Model: 794380-208 EShear Valve(s) (Functional test) EShear Valve(s) (Functional test) E Fire extinguisher inspected and tagged: EOK E]Not OK E Fire extinguisher inspected and to ed: NOK ❑Not OK Dispenser ID: 5&6 N Sump: EDry[]water[]Product Dispenser ID:7&8 E Sump: EDry❑Water[]Product NDispenser Containment Sensor(s). Model:794380-208 NDispenser Containment Sensor(s). Model: 794380-208 EShear Valve(s) (Functional test) EShear Valve(s) (Functional test) N Fire extinguisher inspected and tagged: NOK ❑Not OK N Fire extinguisher inspected and tagged: NOK ❑Not OK Dispenser ID: 9&10 E Sump: EDry❑Water❑Product Dispenser ID: 118,12 E Sump: EDry❑Water[]Product NDispenser Containment Sensor(s). Model: 794380-208 El Dispenser Containment Sensor(s). Model: 794380-208 EShear Valves) (Functional test) EShear Valve(s) (Functional test) N Fire extin uisher ins ected and tagged: NOK ❑Not OK N Fire extinguisher inspected and tagged: EOK ❑Not OK 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 a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report; ® System set-up ®Alarm history report Technician: Date: 3/08/12 Certification: Veeder-Root 836877, Level 4 ICC UST Service Technician # 8011608-UT