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5• , P.O.Box 4208 Sonora CA 95370 A to • Ca:623541 A-Haz C Pe t� Phone:209-532-7320 Compliance without Compromise Fax:209-533-2650 mai I@al ltech petro.com www.aIItechpetro.com MONITORING SYSTEM CERTIFICATION A. General Information Facility Name: Costco #658 Tracy Date of Testing/Servicing: September 18, 2018 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: Zuna Barker; LIA Phone: 209-953-7311; email: zbarker@sjcehd.com Make/Model of Monitoring System: Veeder-Root TLS-350 B. Inventory of Equipment Tested/Certified: Tank ID:Tank 1 Unleaded 87A Tank ID:Tank 2 Unleaded 87B •In-Tank Gauging Probe. Model: Mag 1 ®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 ®Electronic Line Leak Detector. Model:VR PLLD ®Electronic 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 N Fillspill Bucket Tested: ®Pass ❑Fail • Fire extinguishers inspected and tagged: NOK ❑Not OK N Fire extinguishers inspected and tagged: •OK ❑Not OK Tank ID:Tank 3 Unleaded 91 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 NPiping/Fill Sump Sensor(s). Model: 793380-323 ®Fill Sump Sensor(s). Model: 793380-208 ❑Fill Sump annular. Model: 794380-304 ❑Electronic Line Leak Detector. Model:VR PLLD NMechanical Line Leak Detector. Model: Fe Petro ❑Tank Overfill/High-Level Sensor. Model:V-R Audible ❑Tank Overfill/High-Level Sensor. Model:V-R Audible N Fillspill Bucket Tested: NPass ❑Fail • Fillspill Bucket Tested: ❑Pass ❑Fail • Fire extinguishers inspected and tagged: •OK ❑Not OK • Fire extinguishers inspected and tagged: •OK ❑Not OK Dispenser ID: 1&2 N Sump: NDry❑Water❑Product Dispenser ID:3&4 N Sump: ®Dry❑Water❑Product •Dispenser Containment Sensor(s). Model: 794380-208 N Dispenser Containment Sensor(s). Model:794380-208 ❑Shear Valve(s) (Functional test) NShearValve(s) (Functional test) • Fire extinguisher inspected and tagged: NOK ❑Not OK • 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 •Dispenser Containment Sensor(s). Model: 794380-208 ❑Dispenser Containment Sensor(s). Model:794380-208 •Shear Valve(s) (Functional test) •Shear Valves) (Functional test) • Fire extinguisher inspected and tagged: NOK ❑Not OK • Fire extinguisher inspected and tagged: •OK El Not OK Dispenser ID: 9&10 N Sump: NDry❑Water❑Product Dispenser ID: 11&12 • Sump: •Dry❑Water❑Product •Dispenser Containment Sensor(s). Model: 794380-208 NDispenser Containment Sensor(s). Model: 794380-208 •Shear Valves) (Functional test) NShear Valves) (Functional test) • Fire extinguisher inspected and tagged: •OK ❑Not OK • Fire extinguisher inspected and tagged: •OK ❑Not OK Dispenser ID: Vent Box N Sump: NDry[—]water❑Product Dispenser ID: ❑ Sump: ❑Dry❑Water[]Product • Dispenser Containment Sensor(s). Model: 793380-323 E]Dispenser Containment Sensor(s). Model: • UDC Annular Space Sensor. Model: 794380-304 ❑Shear Valve(s) (Functional test) • Fire extinguisher inspected and tagged: •OK ❑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; N system set-up N Alarm history report Technician: Date: 09/18/18 Certification: Veeder-Root 836878, Level 4 ISD; ICC UST Service Technician # 8146912-UT.