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41ar 24 05 10: 53a MikDotten (209) 533-2650 P. 1 i Alltech 17759 Buttercup Circle, Sonora, CA 95370 Phone: 209-532-7320; Fax: 209-533-2650 California Contractor 623541 A-Haz Afike@AlltechPetro.com �Fal MONITORING SYSTEM CERTIFICATION A. General Information Facility Name: Costco # 038 Stockton Date of Testing/Servicing: March 22,2005 Facility Address:1616 W. Hammer Lane, Stockton CA Facility Contact Person: Rich Medeiros(Ser. Sta. Supervisor); Facility Phone: (209)478-2040 LIA: San Joaquon Health; Inspector: Michelle Le;LIA Phone: (209) 468-9847; LIA Fax: (209) 468-3433 Make/Model of Monitoring System: Veeder-Root TLS-350 B. Invento of Equipment Tested/Certified: Tank ID:Regular 1 Tank Tank ID:Regular 2 Tank N ht-Tank Gauging Probe. Model:Mag 1 N In-Tank Gauging Probe. Model:Mag 1 ®Annular Space Sensor. Model:Single-Float Brine ®Annular Space Sensor. Model:Single-Float Brine N Brine level:6.25" Adjusted to: N Brine level:7"" Adjusted to: ®Piping Sump Sensor(s). Model:Discriminating Sensor ®Piping Sump Sensor(s). Model:Discriminating Sensor ®Fill sump sensor(s). Model:Discriminating Sensor ®Fill Sump Sensm(s). Model:Discriminating Sensor N Electronic Line leak Detector. Model:PLLD N Electronic Line Leak Detector. Model:PLLD ®Tank Overfill/High-Level Sensor. Madel:V.R Audible N Tank Overfill/High-Level Sensor. Model:V-R Audible N Fillspill Bucket Tested: ®Pass ❑Fail N Fillspill Bucket Tested: ®Pass []Fail ® Fire extinguishers inspected and tagged: NOK ❑Not OK N Fire extinguishers inspected and tagged: NOK ❑Not OK Tank ID:Premimn Tank: Tank ID:None N In-Tank Gauging Probe. Model:Mag 1 ❑In-Tank Gauging Probe. Model: ®Annular Space Sensor. Model:Single-Float Brine ❑Annular Space Sensor, Model: N Brine level:7.5" Adjusted to: ElBrine level: 11Adjusted to: ®Piping Sump sensor(s). Model:Discriminating Sensor ❑Piping Sump Sensor(s). Model: ®Fill Sump Sensor(s). Model:Discriminating Sensor ❑Fill Sump Sensor(s). Model: ®Electronic Line Leak Detector. Model:PLLD ❑ Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model:V-R Audible ❑Tank Overfill/High-Level Sensor. Model: ® Fillspill Bucket Tested ®Pass []Fail ❑Fillspill Bucket Tested: ❑Pass []Fail ® Fire exon uishers cted and ed: NOK ❑Not OK ❑ Fire exon fishers in ected and to ed []OK ❑Not OK Dispenser D} 1&2 N Sump:®Dry❑Water❑Product Dispenser ID:3&4 N Sump:®Dry❑Water❑Product ®Dispenser Containment Sensor(s). Model:Non-Discriminating N Dispenser Containment Sensor(s). Model:Non-Discriminating ®Shear Valve(s) (Functional test) N Shear Valve(s) (Functional test) ® Fire a 'sher ins ted and to : NOK ❑Not OK ® Fireexon 'skier ted and ed: ®OK ❑Nat OK Dispenser ID:5&6 N Sump:®Dry❑Water❑Product Dispenser ID:7&8 N Sump: NDry[]Water❑Product ®Dispenser Containment Sensor(s). Model:Non-Discriminating N Dispenser Containment Senscr(s). Model:Non-Discriminating ®Shear Valve(s) (Functional test) N Shear Valve(s) (Functional test) ® Fire er in cted and tagged. ®OK ❑Not OK ® Fire extinguisher inspected and ed: NOK []Not OK Dispenser ID:9&10 N Sump:NDry❑Water❑Product Dispenser ID: 11&12 N sump:NDry❑Water❑Product N Dispenser Containment Sensor(s). Model:Non-Discriminating ®Dispenser Contaimnent Sensor(s). Model:Non-Discrim ating ®Shear Valves) (Functional test) N Shear Valve(s) (Functional test) ® Fire extin 'sher= cted and ed: NOK ❑Not OK ® Fire extin isher' ted and ted NOK []Not OK Dispenser ID: ❑Sump:[]Dry[]Water[-]Product Dispenser 1D: ❑Stump:❑Dry❑Water❑Product ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s) (Functional test) ❑Shcar Valve(s) (Functional test) ❑ Fire 'skier j ected and tagged: ❑OK []Not OK ❑ Fre extin rusher ins ted and!Med: ❑OK ❑Not OK G Certification-I certify that the equipment identified In this document ass impeded/serviced in accordance with the manufacturers'guidelines. Attached to this Certification n a Plot Plan showing the layout of monitoring equipment For anyequipment capable of generating Tach reports,I have also attached a copy of the mport ®System set-up ®Alarmlarm_Mstory report Technician: 14"9 Y J�LrIJW— Mike Dotten,California Contractor 623541 A-Haz Certification:Veeder-Root:006-05-0789;Level 4.