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RECEIVED P.O.Box 4208 All tech�etrrrrr ' Sonora 53 -7370 Ca:623541 A-Haz QCT O 6 2014 Phone:209-532-7320 Compliance without Compromise Fax:209-533-2650 ENVIRONMENTAL HEALTQ alltechpetrocom MONITORING SYSTEM CERTIFleAfMMENT A. General Information Facility Name: Costco#658 Tracy Date of Testing/Servicing: September 25, 2014 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: Elena Manzo; LIA Phone: 209-468-3440; LIA Fax: 209-468-8392 Make/Model of Monitoring System: Veeder-Root TLS-350 B. Inventory of Equipment Tested/Certified: Tank ID:87 A Tank Tank ID:87 B Tank ®In-Tank Gauging Probe. Model: Mag 1 EIn-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 ®Electronic Line Leak Detector. Model:VR PLLD RElectronic Line Leak Detector. Model:VR PLLD NTank Overfill/High-Level Sensor. Model:V-R Audible RTank Overfill/High-Level Sensor. Model:V-R Audible R Fillspill Bucket Tested: RPass ❑Fail N Fillspill Bucket Tested: RPass ❑Fail R Fire extinguishers inspected and tagged: ROK [-]Not OK E Fire extinguishers inspected and tagged: ROK ❑Not OK Tank ID:91 Tank Tank ID:Additive Tank E In-Tank Gauging Probe. Model: Mag 1 Nln-Tank Gauging Probe. Model: Mag Plus NAnnular Space Sensor. Model: 794380-301 RAnnular Space Sensor. Model:794380-303 NPiping Sump Sensor(s). Model: 793380-352 ❑Piping/Fill Sump Sensor(s). Model:793380-323 N Fill Sump Sensor(s). Model:793380-208 NFill Sump annular. Model: 794380-304 E Electronic Line Leak Detector. Model:VR PLLD NMechanical Line Leak Detector. Model: Fe Petro NTank Overfill/High-Level Sensor. Model:V-R Audible NTank Overfill/High-Level Sensor. Model:V-R Audible R Fillspill Bucket Tested: NPass []Fail R Fillspill Bucket Tested: ❑Pass []Fail N Fire extinguishers inspected and to ed: NOK ❑Not OK E Fire extinguishers inspected and tagged: NOK ❑Not OK Dispenser ID: 1&2 N Sump: EDry❑Water❑Product Dispenser ID:38,4 R Sump: NDry❑Water❑Product RDispenser Containment Sensor(s). Model: 794380-208 E Dispenser Containment Sensor(s). Model: 794380-208 RShear Valve(s) (Functional test) RShear Valve(s) (Functional test) N Fire extinguisher inspected and tagged: NOK ❑Not OK R Fire extinguisher inspected and tagged: ROK ❑Not OK Dispenser ID:58,6 E Sump: RDry❑Water❑Product Dispenser ID: 7&8 E Sump: RDry❑Water❑Product N Dispenser Containment Sensor(s). Model: 794380-208 RDispenser Containment Sensor(s). Model:794380-208 RShear Valve(s) (Functional test) RShear Valve(s) (Functional test) N Fire extinguisher inspected and tagged: NOK ❑Not OK N Fire extinguisher inspected and tagged: ROK ❑Not OK Dispenser ID: 9&10 N Sump: RDry[]Water❑Product Dispenser ID: 11&12 E Sump: NDry❑Water[]Product RDispenser Containment Sensor(s). Model:794380-208 ❑Dispenser Containment Sensor(s). Model:794380-208 RShear Valves) (Functional test) RShear Valve(s) (Functional test) R Fire extinguisher inspected and tagged: NOK ❑Nat OK E Fire extinguisher inspected and tagged: NOK ❑Not OK Vent Box: NONE E Sump: NDry❑Water❑Product Dispenser ID: E ❑ Sump: ❑Dry[]Water❑Product R Dispenser Containment Sensor(s). Model: 793380-323 ❑Dispenser Containment Sensor(s). Model: R UDC Annular Space Sensor. Model: 794380-304 ❑Shear Valve(s) (Functional test) N Fire extinguisher inspected and tagged: ROK ❑Not OK ❑ 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; 0 System set-up ®Alarm history report Technician: Date: 9/25/14 Certification: Veeder-Root 836877, Level 4 ISD; ICC UST Service Technician # 8152115-UT.