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r: Alltech Petro Inc. OCT 072010 P.O. Box 4208, Sonora, CA 95370 Phone: 209-532-7320; Fax: 209-533-2650 SANJOAQU; ] cfhmail( a4me com Contractor 623541 A-Hoz l�a C ,'SR7MEP IN MONITORING SYSTEM CERTIFICATION A. General Information Facility Name: Costco#658 Tracy Date of Testing/Servicing: September 28,2010 Facility Address: 3250 W Grant Line Rd.,Tracy CA 95304 Service Station Supervisor: Robert Mendoza Hut Phone: 209-834-1247 Warehouse Phone: 830-5343 LIA: San Joaquin Health; Inspector: Stacy Rivera; LIA Phone: 209468-3440; LIA Fax: 209468-8392 Make/Model of Monitoring System: Veeder-Root TLS-350 B. Inventory of Equipment Tested/Certified: Tank ID:Regular 1 Tank Tank ID:Regular 2 Tank M In-Tank Gauging Probe. Model:Mag 1 M In-Tank Gauging Probe. Model:Mag 1 ®Annular Space Sensor. Model:794380-301 ®Annular 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 ®Fillspill Bucket Tested: ®Pass ❑Fail ®Fillspill Bucket Tested: ®Pass ❑Fail ® Fire extinguishers inspected and tagged: MOK ❑Not OK ® Fire extinguishers ins ted and tagged: MOK ❑Not OK Tank ID:Premium Tank: Tank ID:None M In-Tank Gauging Probe. Model:Mag 1 ❑In-Tank Gauging Probe. Model: ®Annular Space Sensor. Model:794380-301 ❑Annular Space Sensor. Model: ®Piping Sump Sensor(s). Model:793380-352 ❑Piping Sump Sensor(s). Model: ®Fill Sump Sensor(s). Model:793380-208 ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model:VR 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 extinguishers insviuccteciand tagged: MOK []NotOK ❑ Fire extinguishers inspected and tagged: ❑OK []Not OK Dispenser ID: 1&2 M Sump:®Dry❑Water❑Product Dispenser ID:3&4 M Sump:®Dry❑Water[]Product M Dispenser Containment Sensor(s). Model:794380-208 M Dispenser Containment Sensor(s). Model:794380-208 M Shear Valve(s) (Functional test) ®Shear Valve(s) (Functional test) ® Fire extinguisher inspected and tagged: MOK []Not Ok M Fire extinguisher inspected and tagged: MOK ❑Not OK Dispenser ID:5&6 M Sump:®Dry❑Water❑Product Dispenser ID:7&8 M Sump:MDry❑Water❑Product M Dispenser Containment Sensor(s). Model:794380-208 M Dispenser Containment Sensor(s). Model:794380-208 ®Shcar Valves) (Functional test) M Shear Valve(s) (Functional test) M Fire extinguisher inspected and tagged: MOK ❑Not OK M Fire extinguisher inspected and tagged: MOK ❑Not OK Dispenser ID:9&10 M Sump:MDry❑Water❑Product Dispenser ID: 11&12 M Sump:MDry❑Water❑Product ®Dispenser Containment Sensor(s). Model:794380-208 M Dispenser Containment Sensor(s). Model:794380-208 M Shear Valves) (Functional test) ®Show Valve(s) (Functional test) M Fire extinguisher inspected and tagged: MOK ❑Not OK M Fire extin isher instiected and tagged: MOK ❑Not OK Dispenser ID:NONE❑Sump:❑Dry❑Water[]Product Dispenser ID:NONE❑Sump: []Dry❑Water❑Product ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valvc(s) (Functional test) ❑Shear Valve(s) (Functional test) ❑ Fire extinguisher inspected and tagged: ❑OK [--]Not OK ❑ Fire extinguisher inspected and tagged: ❑OK []Not OK C. Certification - 1 certify that the equipment identified in this document was impected/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,1 have also attached a copy of the report; M System set-up M Alarm history report Technician: Date:9/28/10 Certification: Veeder-Root 836878,Level 4 ISD; ICC UST Service Technician#8005930-UT.