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t t U AifitechPetr Compliance without Compromise MAR 3 0 2012 GAN JOAQUIN COUNTY �3N'P';i IONP,4ENTAL MONITORING SYSTEM CER-1rIB j'"AT[ON A. General Information P.O. Box 4208 Sonora CA 95370 Ca: 623541 A-Haz Phone: 209-532-7320 Fax: 209-533-2650 mail@alltechpetro.com www.alitechpetro.com Facility flame: Costco # Village West Marina Date of Testing/Servicing: March 21, 2012 Facility Address:6649 Embarcadero, Stockton CA 95217 Facility Contact Person: Mike Spence Facility Phone: (209) 951-1551 LIA: San Joaquin Health; Inspector: Garrett Backus; LIA Phone: 209-468-9847; LIA Fax: 209-468-3433 Make/Model of Monitoring System: Veeder-Root TLS -350i LIA Email: gbackus@sjcehd.com 3. Inv(?ntory of Equipment Tested/Certified: Tank ID: Premium 91 Tank Tank ID: Diesel Tank ❑In -Tank Gauging Probe. Model: None ❑In -Tank Gauging Probe. Model: None ®Annular Space Sensor. Model: 794380-344 ®Annular Space Sensor. Model: 794380-344 ®Piping Sump Sensor(s). Model: 792380-208 ®Piping Sump Sensor(s). Model: 792380-208 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ®Mechanical Line Leak Detector. Model: VMI LD -2000 ®Mechanical Line Leak Detector. Model: VMI LD -2000 ®Tank: Overfill / High -Level Sensor. Model: Flapper Valve ®Tank Overfill / High -Level Sensor. Model: Flapper Valve ® Fillspill Bucket Tested: ®Pass ❑Fail ® Fillspill Bucket Tested: ®Pass ❑Fail ❑ Fire- extinguishers inspected and tagged: ❑OK ❑Not OK ❑ Fire extinguishers inspected and tagged: ❑OK []Not OK Tank ID: Tank ID: None ❑ In -Tank Gauging Probe. Model: ❑In -Tank Gauging Probe. Model: ❑Annular Space Sensor. Model: ❑Annular Space Sensor. Model: ❑ Piping Sump Sensor(s). Model: []Piping Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: []Fill Sump Sensor(s). Model: ❑ Line Leak Detector. Model: ❑ line Leak Detector. Model: ❑Tank: Overfill / High -Level Sensor. Model: ❑Tank Overfill / High -Level Sensor. Model: ❑ Fillspill Bucket Tested: ❑Pass ❑Fail ❑ Fillspill Bucket Tested: ❑Pass ❑Fail ❑ Fire extin uishers inspected and tagged: ❑OK ❑Not OK ❑ Fire extinguishers inspected and tagged: ❑OK ❑Not OK Dispenser ID: Transition Sump ® Sump: ®Dry ❑Water ❑ Dispenser ID: 1 ® Sump: ®Dry ❑Water ❑Product Product ®Dispenser Containment Sensor(s). Model: Float & Chain ®Dispenser Containment Sensor(s). Model: 792380-208 ®Shear Valve(s) (Functional test) ❑Shear Valve(s) (Functional test) ❑ Fire extinguisher inspected and tagged: ❑OK ❑Not OK ❑ Fire extinguisher inspected and tagged: ❑OK ❑Not OK Dispenser ID: 2 ® Sump: ®Dry ❑Water ❑Product Dispenser ID: 3 ® Sump: ®Dry ❑Water ❑Product ®Dispenser Containment Sensor(s). Model: Float & Chain ®Dispenser Containment Sensor(s). Model: Float & Chain O Shear Valve(s) (Functional test) ❑ Shear Valve(s) (Functional test) ❑ Fire extinguisher inspected and tagged: ❑OK ❑Not OK ❑ Fire extinguisher inspected and tagged: ❑OK ❑Not OK Dispenser ID: ❑ Sump: ❑Dry ❑Water ❑Product Dispenser ID: ❑ Sump: ❑Dry ❑Water ❑Product ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑Shear Valve(s) (Functional test) El Shear Valve(s) (Functional test) ❑ Fire extinguisher inspected and tagged: ❑OK []Not OK ❑ Fire extinguisher inspected and tagged: ❑OK ❑Not OK Dispenser ID: ❑ Sump: ❑Dry ❑Water ❑Product Dispenser ID: ❑ Sump: ❑Dry ❑Water ❑Product ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑Shear Valve(s) (Functional test) E] 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; ® System set-up ® Alarm history report Technician: Certification: Veeder-Root 836878, Level 4 ICC UST :Service Technician # 8005930 -UT Date: 3/21/2012