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P.O.Box 4208 <br /> An -0 RE(tIVED Sonora CA 95370 <br /> Ca:623541 A-Haz <br /> A lite ch Pe tr a., <br /> Phone:209-532-7320 <br /> Compliance without Compromise J2015Fax:209-533-2650 <br /> mail@alltechpetro.com <br /> ENVIRONMENTALwww.alltechpetro.com <br /> TP <br /> MONITORING SYSTEM CERTIFICATION or VPN SYSTEM'S <br /> A. Facility General Information <br /> Facility Name:Costco#1091 Lodi Date of Testing: 5/19/15 <br /> Facility Address:2680 Reynolds Ranch Rd., Lodi CA <br /> Facility Contact Person: Rick Medeiros Facility Phone:209-366-7332 <br /> LIA: San Joaquin County EHD;Inspector:Aris Cacapit. Email:Aris Cacapit <acacapit@sjcehd.com> <br /> Make/Model of Monitoring System:Veeder-Root TLS-350 <br /> B. Invento of Equipment Tested/Certified: <br /> Tank 87A Tank ID:87B <br /> ®In-Tank Gauging Probe. Model: Mag Plus Nln-Tank Gauging Probe. Model: Mag Plus <br /> NTank Annular Space Sensor. Model:794380-301 ®Tank Annular Space Sensor. Model: 794380-301 <br /> ®Piping Sump Sensor(s). Model:857080-112 NPiping Sump Sensor(s). Model: 857080-112 <br /> NPiping Sump Annular: Model:794380-304 NPiping Sump Annular: Model: 794380-304 <br /> NFill Sump Sensor(s). Model:794380-323 ®Fill Sump Sensor(s). Model:794380-323 <br /> ®Fill Sump annular Model:794380-304 ®Fill Sump annular Model:794380-304 <br /> ®Secondary Piping monitor Type:Vacuum ®Secondary Piping monitor Type:Vacuum <br /> ®Electronic Line Leak Detector. Model:VR-PLLD ®Electronic Line Leak Detector. Model:VR-PLLD <br /> NTank Overfill/High-Level Sensor. Model:VR Audible NTank Overfill/High-Level Sensor. Model:VR Audible <br /> N Fills ill Bucket Tested: ®Pass ❑Fail N Fills ill Bucket Tested: ®Pass ❑Fail <br /> Tank ID: 91 Tank ID:Additive Tank <br /> [0In-TankGauging Probe. Model: Mag Plus Nln-Tank Gauging Probe. Model: Mag Plus <br /> NTank Annular Space Sensor. Model:794380-301 NTank Annular Space Sensor. Model: 794380-303 <br /> NPiping Sump Sensor(s). Model:857080-112 NPiping/Fill Sump Sensor(s). Model:794380-323 <br /> NPiping Sump Annular: Model:794380-304 NPiping/Fill Sump annular sensor Model: 794380-304 <br /> ®Fill Sump Sensor(s). Model: 794380-323 ®Secondary Piping monitor Type:Vacuum <br /> ®Fill Sump annular Model: 794380-304 ®Mechanical Line Leak Detector. Model: FE Petro <br /> ®Secondary Piping monitor Type:Vacuum NTank Overfill/High-Level Sensor. Model:VR-Audible <br /> ®Electronic Line Leak Detector. Model:VR-PLLD N Fillspill Bucket Tested: ®Pass ❑Fail <br /> NTank Overfill/High-Level Sensor. Model:VR Audible <br /> N Fills ill Bucket Tested: NPass ❑Fail <br /> Dispenser ID: 1&2 N Sump: NDry❑Water❑ProductDisperser ID: 3&4 N Sump: NDry❑Water❑Product <br /> N Dispenser Containment Sensor(s).Model:794380-323 N Dispenser Containment Sensor(s). Model:794380-323 <br /> N UDC Annular sensor. Model: 794380-304 N UDC Annular sensor. Model: 794380-304 <br /> NShearValve(s) (Functional test) Shear Valve(s) (Functional test) <br /> Dispenser ID: 5&6 N Sump: NDry❑Water❑Product Dispenser ID: 7&8 N Sump:,NDry❑Water❑Product <br /> N Dispenser Containment Sensor(s).Model:794380-323 ®Dispenser Containment Sensor(s).Model:794380-323 <br /> ® UDC Annular sensor. Model: 794380-304 N UDC Annular sensor. Model:794380-304 <br /> ®Shear Valves) (Functional test) ®Shear Valve(s) (Functional test) <br /> Dispenser ID:9&10 N Sump: NDry❑Water❑Product Dispenser ID: 11&12 N Sump: NDry❑Water❑Product <br /> ®Dispenser Containment Sensor(s). Model: 794380-323 ®Dispenser Containment Sensor(s).Model:794380-323 <br /> N UDC Annular sensor. Model:794380-304 N UDC Annular sensor. Model: 794380-304 <br /> NShear Valve(s) (Functional test) ®Shear Valve(s) (Functional test) <br /> Dispenser ID: 13&14 N Sump: NDry❑Water❑Product Dispenser ID: 15&16 N Sump: NDry❑Water❑Product <br /> ®Dispenser Containment Sensor(s). Model: 794380-323 NDispenser Containment Sensor(s). Model:794380-323 <br /> ® UDC Annular sensor. Model:794380-304 N UDC Annular sensor. Model: 794380-304 <br /> NShear Valve(s) (Functional test) ®Shear Valve(s) (Functional test) <br /> Tank Vent Box N Sump: NDry❑Water❑Product Adtve Vent Box N Sump: NDry❑Water❑Product <br /> N Sump Containment Sensor(s). Model:794380-323 N Sump Containment Sensor(s).Model:794380-323' <br /> N Sump Annular sensor. Model:794380-304 N Sump Annular sensor. Model:794380-304 <br /> N Shear Valve(s) (Functional test) N Shear Valve(s) (Functional test) <br /> Technician:.00 <br /> Veeder-Root: 836877 Level 4 ICC UST Technician #8152115-UT. Date:05/19/15 <br />