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P.O.Box 4208 All techPetr'Bw ' Sonora 370 Ca:623541 A-Haz Phone:209-5353 2-7-7320 Compliance without Compromise Fax:209-533-2650 ma i I@al(tech petro.com www.alltechpetro.com MONITORING SYSTEM CERTIFICATION A. General Information Facility Name: Costco#658 Tracy Date of Testing/Servicing: September 25, 2013 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/Certified: Tank ID:87 A Tank Tank ID:87 B Tank ®In-Tank Gauging Probe. Model: Mag 1 ®In-Tank Gauging Probe. Model: Mag 1 NAnnular Space Sensor. Model:794380-301 ®Annular Space Sensor. Model: 794380-301 NPiping Sump Sensor(s). Model:793380-352 [0 Piping Sump Sensor(s). Model: 793380-352 NFill Sump Sensor(s). Model:794380-352 NFill Sump Sensor(s). Model: 793380-352 ED Electronic Line Leak Detector. Model:VR PLLD NElectronic Line Leak Detector. Model:VR PLLD NTank Overfill/High-Level Sensor. Model:V-R Audible NTank Overfill/High-Level Sensor. Model:V-R Audible N Fillspill Bucket Tested: NPass ❑Fail N Fillspill Bucket Tested: NPass ❑Fail N Fire extinguishers inspected and tagged: NOK ❑Not OK N Fire extinguishers inspected and tagged: NOK []NotOK Tank ID: 91 Tank Tank ID:Additive Tank N In-Tank Gauging Probe. Model: Mag 1 Nln-Tank Gauging Probe. Model: Mag Plus NAnnular Space Sensor. Model: 794380-301 NAnnular Space Sensor. Model: 794380-302 NPiping Sump Sensor(s). Model: 793380-352 NPiping/Fill Sump Sensor(s). Model: 793380-323 N Fill Sump Sensor(s). Model: 793380-208 NFill Sump annular. Model:794380-304 NElectronic Line Leak Detector. Model:VR PLLD NMechanical Line Leak Detector. Model: Fe Petro NTank Overfill/High-Level Sensor. Model:V-R Audible []Tank Overfill/High-Level Sensor. Model:V-R Audible N Fillspill Bucket Tested: NPass ❑Fail N Fillspill Bucket Tested: []Pass ❑Fail N Fire extinguishers inspected and tagged: NOK ❑Not OK N Fire extinguishers inspected and tagged: NOK []NotOK Dispenser ID: 1&2 N Sump:NDry❑Water❑Product Dispenser ID: 3&4 N Sump: NDry❑Water❑Product NDispenser Containment Sensor(s).Model: 794380-208 1Z Dispenser Containment Sensor(s). Model:794380-208 NShear Valve(s) (Functional test) NShear Valves) (Functional test) N Fire extinguisher inspected and to ed: NOK ❑Nat OK N Fire extinguisher inspected and tagged: NOK ❑Not OK Dispenser ID: 5&6 N Sump:NDry❑Water❑Product Dispenser ID: 7&8 N Sump: NDry❑Water❑Product N Dispenser Containment Sensor(s). Model: 794380-208 N Dispenser Containment Sensor(s). Model: 794380-208 NShear Valve(s) (Functional test) NShear Valve(s) (Functional test) N Fire extinguisher inspected and tagged: NOK ❑Not OK N Fire extinguisher inspected and tagged: NOK ❑Not OK Dispenser ID: 9&10 N Sump: NDry❑Water[7]Product Dispenser ID: 11&12 N Sump: NDry[-]water❑Product NDispenser Containment Sensor(s). Model: 794380-208 NDispenser Containment Sensor(s). Model: 794380-208 NShear Valve(s) (Functional test) NShear Valve(s) (Functional test) N Fire extinguisher inspected and tag ed: NOK ❑Not OK N Fire extinguisher inspected and tagged: NOK ❑Not OK Vent Box: NONE N Sump: NDry❑Water❑Product Dispenser ID:E❑ Sump: ❑Dry ❑Water[]Product N Dispenser Containment Sensor(s). Model: 793380-323 ❑Dispenser Containment Sensor(s). Madel: N UDC Annular Sp ace Sensor. Model:794380-304 ❑Shear Valve(s) (Functional test) N Fire extin uisher inspected and tagged: NOK ❑Not OK ❑ Fire extinguisher inspected and to ed: ❑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; N System set-up ®Alarm history report Technician: .004 Date: 9/25/13 Certification: Veeder-Root 836877, Level 4 ISD; ICC UST Service Technician # 8152115-UT.