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RECRIVED P.O.Box 4208 Sonora CA 95370 Alitech SEP 3 0 2016 Ca:623541 A-Haz Compliance without Compromise Phone:209-532-7320 p ENVIRONMENTAL HEALTH Fax:209-533-2650 DEPARTMENT mail@al[tech petro.mm MONITORING SYSTEM CERTIFICATION www.alltechpetro.com A. General Information Facility Name: Costco #658 Tracy Date of Testing/Servicing: September 22, 2016 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:Tank 1 87A Tank ID: Tank 2 87B NIn-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 ®Fill Sump Sensor(s). Model: 794380-352 NFiII Sump Sensor(s). Madel: 793380 352 ®Electronic Line Leak Detector. Model:VR PLLD ®Electronic Line Leak Detector, Model: VR PLLD NTank Overfill/High-Level Sensor. Model:V-R Audible ®Tank Overfill/High-Level Sensor. Model:V-R Audible N Fillspilf Bucket Tested: ®Pass ❑Fail N Fillspill Bucket Tested: NPass ❑Fail N Fire extin uishers inspected and tagged: NOK ❑Not OK N Fire extinguishers inspected and to ed: ®OK ❑Not OK Tank ID:Tank 3 87B Tank ID: Tank 4 Additive Tank ® In-Tank Gauging Probe. Model: Mag 1 Nln-Tank Gauging Probe. Model: Mag Plus ®Annular Space Sensor. Model: 794380-301 ®Annular Space Sensor. Model: 794380 303 ®Piping Sump Sensor(s). Model: 793380-352 ®Piping/Fill Sump Sensor(s). Model: 793380-323 NFiII Sump 5ensor(s). Model: 793380-208 ®Fill Sump annular. Model: 794380-304 ®Electronic Line Leak Detector. Model: VR PLLD ®Mechanical Line Leak Detector. Model: Fe Petro ®Tank Overfill/High-Level Sensor. Model:V-R Audible ®Tank Overfill/High-Level Sensor. Model'V-R Audible ® Fillspill Bucket Tested: NPass []Fail N Fillspill Bucket Tested: ®Pass ❑Fail N Fire extin uishers inspected and tagged: NOK []Not OK N Fire extinguishers inspected and tagged: NOK ❑Not OK Fienser ID: 1&2 N Sump: ®pry❑Water❑Product Dispenser ID: 3&4 N Sump: NDry []Water❑Product penser Containment 5ensor(s). Model: 794380-208 ❑Dispenser Containment Sensor(s). Model: 794380-208 ar Vaive(s) (Functional test) ®Shear Valve(s) (Functional test) e extin uisher ins ected and to ed: NOK ❑Not OK N Fire extin uisher ins ected and to ed: NOK ❑Not OKnser ID: 5&6 N Sump: NDry[]Water❑Product Dispenser ID: 7&8 N Sump: ®Dry❑Water❑product ❑Dispenser Containment Sensor(s), Model: 794380-208 ®Dispenser Containment Sensor(s). Model: 794380-208 ®Shear 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❑Product Dispenser ID: 11&12 N Sump: NDry ❑Water❑Product ❑Dispenser Containment Sensor(s). Model: 794380-208 ®Dispenser Containment Sensor(s), Model: 794380-208 ®Shear Valve(s) (Functional test) ®Shear Valve(s) (Functional test) N Fire extinguisher inspected and tagged: ®OK ❑Not OK N Fire extinguisher inspected and tagged: NOK ❑Not OK Dispenser ID: Vent Box N Sump: NDry❑Water[]Product Dispenser ID: ❑ Sump: ❑Dry❑Water❑Product N Dispenser Containment Sensor(s). Madel: 793380-323 ❑Dispenser Containment Sensor(s). Model: N UDC Annular Space Sensor. Model: 794380-304 ❑Shear Valves) (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 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: 09/22/16 Certification: Veeder-Root B36878, Level 4 ISD; ICC UST Service Technician # 8146912-UT. Facility Name: Costco # 658 Tracy (Page 2)