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ECEIVJ® So oraC1 53700 <br /> Ca:AlitechIPAPanP.O.Box 4208 <br /> MAR 13 2017 Phone:209-532-7320 <br /> Complionce without Compromise Fax:209-533-2650 <br /> ENVIRONMENTAL HEALTH mail@alltechpetro.com <br /> w aI(techpetro.corn <br /> DEPARTMENT <br /> MONITORING SYSTEM CERTIFICATION <br /> A. General Information <br /> Facility Name: Costco # 038 Stockton Date of Testing/Servicing: March 2, 2017 <br /> Facility Address:1616 W. Hammer Lane, Stockton CA <br /> Facility Contact Person: Raj Mohan (Ser. Sta. Supervisor); Facility Phone: (209) 478-2040 <br /> LIA: San Joaquin Health; Inspector: Vicki McCartney; 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 /> Eln-Tank Gauging Probe. Model: Mag 1 ®In-Tank Gauging Probe. Model: Mag 1 <br /> ®Tank Annular Space Sensor. Model: 794380-301 ®Tank Annular Space Sensor. Model: 794380-301 <br /> ®Piping Sump Sensor(s). Model: 857080-112 ®Piping Sump Sensor(s). Model: 857080-112 <br /> ®Fill Sump Sensor(s). Model: 794380-323 ®Fill Sump Sensor(s). Model: 794380-323 <br /> ®Fill Sump Annular Sensor. Model: 794380-304 ®Fill Sump Annular Sensor. Model: 794380-304 <br /> ®Electronic Line Leak Detector. Model: PLLD ®Electronic Line Leak Detector. Model: PLLD <br /> NTank Overfill/High-Level Sensor. Model:V-R Audible ®Tank Overfill/High-Level Sensor. Model:V-R Audible <br /> N Fillspill Bucket Tested: NPass ❑Fail E Fillspill Bucket Tested: NPass []Fail <br /> M Fire extinguishers ins ected and tagged: NOK ❑Not OK E Fire extinguishers inspected and tagged: 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 Eln-Tank Gauging Probe. Model: Mag 1 <br /> NAnnular Space Sensor. Model: 794380-301 NTank Annular Space Sensor. Model: 794380-303 <br /> NPiping Sump Sensor(s). Model: 857080-112 NPiping/Fill Sump Sensor(s). Model: 794380-323 <br /> E Fill Sump Sensor(s). Model: 794380-323 NPiping/Fill Sump Annular Sensor. Model: 794380-304 <br /> EFill Sump Annular Sensor. Model: 794380-304 MMechanical 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 /> N Fillspill Bucket Tested: NPass ❑Fail N Fire extinguishers inspected and tagged: NOK ❑Not OK <br /> M Fire extinguishers inspected and tagged: NOK.❑Not OK <br /> Dispenser ID: 1&2 E Sump: NDry❑Water❑Product Dispenser ID: 3&4 N Sump: NDry❑Water❑Product <br /> ®Dispenser Containment Senso r(s). Model: 7 943 80-2 08 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: MOK El Not OK M Fire extinguisher inspected and tagged: EOK ❑Not OK <br /> Dispenser ID: 5&6 N Sump: NDry❑Water❑Product Dispenser ID: 7&8 N Sump: MDry❑Water❑Product <br /> M Dispenser Containment Sensor(s). Model: 794380-208 E Dispenser Containment Sensor(s). Model:794380-208 <br /> NShear Valve(s) (Functional test) NShear Valve(s) (Functional test) <br /> N Fire extinguisher inspected and tagged: MOK ❑Not OK E Fire extinguisher inspected and tagged: NOK ❑Not OK <br /> Dispenser ID: 9&10 N Sump: NDry❑Water❑Product Dispenser ID: 11&12 E Sump: NDry❑Water E]Product <br /> M Dispenser 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 /> E Fire extinguisher inspected and tagged: NOK E]Not OK E Fire extinguisher inspected and tagged: NOK ❑Not OK <br /> Dispenser ID:Vent Stack E Sump:EDry❑Water❑Product Dispenser ID:Adtiv Vent E Sump:NDry❑Water❑Product <br /> ESump Containment Sensor(s). Model: 794380-323 ESump Containment Sensor(s). Model: 794380-323 <br /> ❑Sump Annular Sensor(s). Model: ESump Annular Sensor(s). Model: 794380-304 <br /> N Fire extin uisher inspected and tagged; MOK El Not OK E 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: Date: 3/2/17 <br /> Certification: Veeder-Root 836877, Level 4 <br /> ICC UST Service Technician # 8152115-UT <br /> Q►"b 5l�b(�2�' <br />