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P.O.Box 4208 Sonora CA 95370 AiltechPetr'"6- j� Ca:623541 -73 a0 Phone:209-532-730 Compliance without Compromise �- �� tan :., Fax:209-533-265x, mail@alltechpetro.com A�w.jllt6ch�.4 �4.com MONITORING SYSTEM CERTIFICATION A. General Information s�,NJo�,cr,';S.Cc�LlNrr Facility Name: Costco # Village West Marina Date of Testing/Servicing: March 23, 2011 I"°,LTH C`_a, sTtv4C�JT 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-3501 LIA Email: gbackus@sjcehd.com B. Inventory 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 extin uishers ins ected 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: F1 Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑ Line Leak Detector. Model: ❑ Line Leak Detector. Model: F1 Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑ Fillspill Bucket Tested: El Pass ❑Fail ❑ Fillspill Bucket Tested: ❑Pass ❑Fail ❑ Fire extinguishers inspected and tagged: ❑OK ❑Not OK ❑ Fire extinguishers inspected and to ed: ❑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) r_1 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 ®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: Ll Dispenser Containment Sensor(s). Model: F-1 Shear Valve(s) (Functional test) E]Shear Valve(s) (Functional test) ❑ Fire extinguisher ins ected 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: F1 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 �0Technician: Date: 3/23/2011 Certification: Veeder-Root B36878, Level 4 ICC UST Service Technician # 8005930-UT