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P.O.Box 4208 All techPetr otiF Sonora CA 370 Ca:623541 A-Haz Phone:209-532-7-7320 Complionce without Compromise Fax:209-533-2650 mail@)alltechpetro.com www.a Iltechpetro.com MONITORING SYSTEM CERTIFICATION A. General Information Facility Name: Costco #658 Tracy Date of Testing/Servicing: September 23, 2015 Facility Address: 3250 W Grant Line Rd., Tracy CA 95304 Service Station Supervisor: Tony Haggard Hut Phone: 209-834-1247 Warehouse Phone: 830-5343 LIA: San Joaquin Health; Inspector: Garrett Backus; 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 Nln-Tank Gauging Probe. Model: Mag 1 ®Annular Space Sensor. Model: 794380-301 ®Annular Space Sensor. Model: 794380-301 NPiping Sump Sensor(s). Model: 793380-352 ®Piping Sump Sensor(s). Model: 793380-352 N Fill Sump Sensor(s). Model: 794380-352 NFill Sump Sensor(s). Model: 793380-352 NElectronic 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 []NotOK N Fire extinguishers inspected and tagged: NOK ❑Not OK 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: 794380-303 NPiping Sump Sensor(s). Model: 793380-352 NPiping/Fill Sump Sensor(s). Model: 793380-323 NFill Sump Sensor(s). Model: 793380-208 [E Fill Sump annular. Model: 794380-304 NElectronic Line Leak Detector. Model:VR PLLD 0Mechanical Line Leak Detector. Model: Fe Petro 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: ❑Pass ❑Fail N Fire extinguishers inspected and tagged: NOK ❑Not OK N Fire extinguishers inspected and tagged: NOK ❑Not OK Dispenser ID: 18,2 N Sump: NDry❑Water❑Product Dispenser ID: 3&4 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 Valves) (Functional test) N Fire extinguisher inspected and tagged: NOK ❑Not 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 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 tagged: NOK ❑Not OK N Fire extinguisher inspected and tagged: NOK []NotOK Dispenser ID:98,10 N Sump: NDry❑Water❑Product Dispenser ID: 118,12 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 tagged: NOK ❑Not OK N Fire extin uisher 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 El Dispenser Containment Sensor(s). Model: N UDC Annular Space Sensor. Model: 794380-304 ❑Shear Valve(s) (Functional test) N Fire extinguisher inspected and tagged: NOK []NotOK ❑ 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 N Alarm history report Technician: 0,0 Date: 9/23/15 Certification: Veeder-Root 836877, Level 4 ISD; ICC UST Service Technician # 8152115-UT.