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� J P.O.Box 4208 All techPetr - Sonora CA 370 Ca:623541 A-Haz Phone:209-532-7-7320 Compliance without Compromise Fax:209-533-2650 mailpalhechpetro.com www.alltechpetro.com MONITORING SYSTEM CERTIFICATION A. General Information Facility Name: Costco #658 Tracy Date of Testing/Servicing: September 21, 2011 Facility Address: 3250 W Grant Line Rd.,Tracy CA 95304 Service Station Supervisor: Troy Dominici Hut Phone: 209-834-1247 Warehouse Phone: 830-5343 LIA: San Joaquin Health; Inspector:Thuy Tran; LIA Phone: 209-468-3440; LIA Fax: 209-468-8392 Make/Model of Monitoring System: Veeder-Root TLS-350 B. Inventory of Equipment Tested/Certifled: Tank ID: Regular 1 Tank Tank ID:Regular 2 Tank Sln-Tank Gauging Probe. Model: Mag 1 Eln-Tank Gauging Probe. Model: Mag 1 ®Annular Space Sensor. Model: 794380-301 SAnnular Space Sensor. Model:794380-301 ®Piping Sump Sensor(s). Model: 793380-352 ®Piping Sump Sensor(s). Model: 793380-352 ®Fill Sump Sensor(s). Model:794380-352 ®Fill Sump Sensor(s). Model:793380-352 ®Mechanical Line Leak Detector. Model:VR PLLD ®Mechanical Line Leak Detector. Model:VR PLLD ®Tank Overfill/High-Level Sensor. Model:V-R Audible ®Tank Overfill/High-Level Sensor. Model:V-R Audible S Fillspill Bucket Tested: EPass ❑Fail E Fillspill Bucket Tested: ®Pass ❑fail S Fire extinguishers inspected and tagged: EOK ❑Not OK E Fire extinguishers inspected and tagged: EOK ❑Not OK Tank ID: Premium Tank: Tank ID:None E In-Tank Gauging Probe. Model: Mag 1 ❑In-Tank Gauging Probe. Model: ®Annular Space Sensor. Model: 794380-301 ❑Annular Space Sensor. Model: N Piping Sump Sensor(s). Model: 793380-352 El Piping Sump Sensor(s). Model: NFill Sump Sensor(s). Model:793380-208 E]Fill Sump Sensor(s). Model: EMechanical Line Leak Detector. Model:VR 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 ❑ Fillspill Bucket Tested: ❑Pass ❑Fail S Fire extinguishers inspected and tagged: NOK ❑Not OK ❑ Fire extinguishers inspected and tagged: ❑OK ❑Not OK Dispenser ID: 1112 E Sump: EDry❑Water❑Product Dispenser ID:3&4 N Sump: NDry❑Water❑Product EDispenser Containment Sensor(s). Model:794380-208 EDispenser Containment Sensor(s). Model: 794380-208 EShear Valve(s) (Functional test) EShear Valve(s) (Functional test) E Fire extinguisher inspected and tagged: NOK ❑Not OK E Fire extinguisher inspected and tagged: EOK ❑Not OK Dispenser ID: 5&6 S Sump:EDry❑Water❑Product Dispenser ID: 7&8 E Sump:EDry❑Water[]Product EDispenser Containment Sensor(s). Model: 794380-208 EDispenser Containment Sensor(s).Model: 794380-208 NShear Valve(s) (Functional test) EShear Valves) (Functional test) E Fire extinguisher inspected and tagged: EOK ❑Not OK N Fire extinguisher inspected and tagged: ECK ❑Not OK Dispenser ID:9&10 E Sump:EDry❑Water❑Product Dispenser ID: 11&12 E Sump: EDry❑Water[]Product EDispenser Containment Sensor(s). Model: 794380-208 EDispenser Containment Sensor(s). Model: 794380-208 EShear Valves) (Functional test) EShear Valve(s) (Functional test) E Fire extinguisher inspected and tagged: SOK ❑Not OK S Fire extinguisher inspected and tagged: SOK ❑Not OK Dispenser ID: NONE❑ Sump: ❑Dry❑Water[]Product Dispenser ID: NONE❑ Sump: ❑Dry❑Water❑Product El Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valves) (Functional test) ❑Shear Valve(s) (Functional test) ❑ Fire extinguisher inspected and tagged: ❑OK ❑Not OK I ❑ Fire extinguisher inspected and tagged: ❑OK ❑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: 9/21/11 Certification: Veeder-Root 836878, Level 4 ISD; ICC UST Service Technician # 8005930-UT.