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r " Sonora CA 95370 <br /> Ca: 623541 A-Haz <br /> A lite ch <br /> COrrJPH017Ce [ri/1!`ftlout Compromise Phone: 209-532-7320 <br /> Fax: 209-533-2650 <br /> mai lea I Itechpetro.co m <br /> www.alltechpetto. 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 . lnventorV of Equipment Tested/Certified : <br /> FTankUnleaded 87A Tank 2 : Unleaded 878 <br /> nk Gauging Probe. Model: Mag Plus ® In-Tank Gauging Probe. Model : Mag Plus <br /> Annular Space Sensor. Model : 794380-301 ® Tank Annular Space Sensor. Model : 794380-301 <br /> g 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 : ® 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 /> ® 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/High -Level Sensor, Model: VR Audible <br /> Fills ill Bucket Tested : ®Pass ❑ Fail <br /> Dispenser ID : 1 &2 ® Sump : ® Dry ❑ Water ❑ Product Dispenser ID: 3 &4 ® Sump: ® Dry ❑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 /> j Dispenser ID: 5 &6 ® Sump: ® Dry ❑ Water ❑ Product Dispenser ID: 7 &8 ® Sump : ® Dry ❑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 ® 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 /> 0 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: 13 & 14 ® Sump : ® Dry ❑Water ❑ Product Dispenser ID: 15&16 ® Sump : ® Dry (]Water ❑ Product <br /> ® Dispense!- 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 /> EUffleadedt Box ® Sump: ® Dry ❑Water ❑ Product Additive Vent Box ® Sump: ® Dry ❑ Water ❑ Producttainment Sensor(s) , Model : 794380-323 ® Sump Containment Sensor(s) . Model : 794380-323ular sensor. Model: 794380-304 ® Sump Annular sensor, Model : 794380-304es Functional test) ® Shear Valves Functional test <br /> yy <br /> Technician : <br /> feeder- Root: B36878 Level 4 ICC UST Technician # 8146912- UT. Date: 05/17/17 <br />