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MU, COX 44U0 <br /> Sonora CA 95370 <br /> Ailtech ,, <br /> Ca : 623541 A-Haz <br /> COMP 017ce Without Compromise Phone: 209-532-7320 <br /> Fax: 209-533-2650 <br /> mai I@all techpetro. corn <br /> www.alltechpetro, com <br /> MONITORING SYSTEM CERTIFICATION for VPH SYSTEM <br /> A. Facility General Information <br /> Facility Name: Costco #1091 Lodi Date of Testing : 05/17/17 <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: Cesar Ruvalcaba <br /> Make/Model of Monitoring System : Veeder-Root TLS-350 Email : cruvalcaba@sjcehd . com <br /> B . Invento y of E ui ment Tested/Certified : <br /> Tank 1 : Unleaded 87A Tank 2 : Unleaded 87B <br /> (� In-Tank Gauging Probe. Model: Mag Plus ® In-Tank Gauging Probe. Model : Mag Plus <br /> ® Tank Annular Space Sensor, Model : 794380-301 Tank Annular Space Sensor. Model : 794380-301 <br /> ® Piping Sump Sensor(s) . Model : 857080- 112 ® Piping Sump Sensor(s) , Model : 857080- 112 <br /> (� Piping Sump Annular: Model : 794380-304 ® Piping Sump Annular: Model : 794380-304 <br /> ® Fill 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 /> ® Tank Overfill/High- Level Sensor. Model : VR Audible ® Tank Overfill/High-Level Sensor. Model : VR Audible <br /> ® Fills ill Bucket Tested : ® Pass ❑ Fail ® Fills ill Bucket Tested : <br /> ® Pass ❑ Fail <br /> Tank 3 : Unleaded 91 Tank 4: Additive <br /> ® In-Tank Gauging Probe. Model : Mag Plus ® In-Tank Gauging Probe. Model : Mag Plus <br /> ® Tank Annular Space Sensor. Model : 794380-301 ® Tank Annular Space Sensor. Model : 794380-303 <br /> ® Piping Sump Sensor(s) . Model : 857080- 112 ® Piping/Fill Sump Sensor(s) , Model : 794380-323 <br /> ® Piping Sump Annular: Model : 794380-304 ® Piping/Fill Sump annular sensor Model : 794380-304 <br /> 3 ® 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 ® Tank Overfill/High -Level Sensor. Model : VR-Audible <br /> ® Electronic Line Leak Detector. Model : VR-PLLD ® Fillspill Bucket Tested : ® Pass ❑ Fail <br /> ® Tank Overfill/Nigh -Level Sensor, Model: VR Audible <br /> Q Fills ill Bucket Tested : ® Pass ❑Fail <br /> Dispenser ID: 1 &2 ® Sump : ® Dry ❑Water ❑ Product Dispenser ID: 3 &4 ® Sump: [RDry ❑Water ❑ Product <br /> ODispenser Containment Sensor(s) . Model: 794380-323 ® Dispenser Containment Sensor(s) . Model : 794380-323 <br />_ ® UDC Annular sensor. Model : 794380-304 ® UDC Annular sensor. Model : 794380-304 <br /> ® Shear Valves Functional test ® Shear Valves Functional test <br /> Dispenser ID: 5&6 ® Sump: ® Dry QWater ❑ Product Dispenser ID: 7 &8 ® Sump: ® Dry QWater ❑ Product <br /> Dispenser Containment Sensor(s) . Model: 794380-323 ® Dispenser Containment Sensor(s) , Model : 794380-323 <br /> ® UDC Annular sensor. Model : 794380-304 ® UDC Annular sensor. Model : 794380-304 <br /> ® Shear Valves Functional test ® Shear Valves Functional test <br /> Dispenser ID: 9&10 ® Sump : ® Dry ❑ Water ❑ Product Dispenser ID: 11 &12 ® Sump : ® Dry []Water ❑ Product <br /> ® Dispenser Containment Sensor(s) , Model: 794380-323 ® Dispenser Containment Sensor(s) . Model : 794380-323 <br /> ® UDC Annular sensor. Model : 794380-304 ® UDC Annular sensor. Model : 794380-304 <br /> ® Shear Valves (Functional test) ® Shear Valve,151, Functional test <br /> Dispenser ID : 13& 14 ® Sump: ®Dry QWater ❑ Product Dispenser ID: 15&16 ® Sump : ® Dry QWater ❑ Product <br /> ® Dispenser Containment Sensor(s) . Model : 794380-323 ® Dispenser Containment Sensor(s) . Model: 794380-323 <br /> ® UDC Annular sensor. Model : 794380-304 ® UDC Annular sensor. Model: 794380-304 <br /> [Unleaded <br /> Shear Valves Functional test) ® Shear Valves (Functional test <br /> Vent Box ® Sump: ® Dry E]Water ❑ Product Additive Vent Box ® Sump: ® Dry (] Water ❑ ProductSump Containment Sensor(s ) . Model : 794380-323 ® Sump Containment Sensor(s) . Model: 794380-323Sump Annular sensor. Model : 794380-304 ® Sump Annular sensor. Model : 794380-304Shear Valves Functional test) ® Shear Valves Functional test) <br /> Technician : _b <br /> Veeder- Root: B36878 Level 4 ICC UST Technician # 8146912- UT. Date: 05/17/ 17 <br />