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UPP Piping Installation Checklist &Warranty Start-up Form <br /> Site Owner: COSTCO FUEL CENTER#658 Installation Contractor: JONES COVEY GROUP,INC. <br /> Site Address: 3250 W Grant Line Rd Address: 9595 LUCAS RANCH ROAD <br /> RANCHO <br /> Site Phone Number: City: CUCAMON.A State: CA Zip: 91730 <br /> City: Tracy —State: CA Zip- 95377 Country USA <br /> Country USA Telephone: (888)-972-7581 <br /> Owner/Operator' COSTCO WHOLESALE Distributor: JF PETROLEUM GROUP <br /> Installation Completion Date: 725/22 <br /> ❑ Complete Fuel Transfer&Containment System uses all FFS Products <br /> Pre-Installation Check: Piping: <br /> W Installer has copy of Installation Guide Total length and model of piping installed at this site: <br /> DO Installer has visually inspected all materials Product line:_0 <br /> for shipping and storage damage Fill Line: 120 <br /> Tank Information: Vent Line 0 <br /> New Tanks Vapor Recovery 120 <br /> UST Manufacturer: CSI <br /> Tank Installation Information: Primary Piping: <br /> Tanks Anchored Pop-up indicators are out and time is marked near fit- <br /> DO Deadman Anchoring ting <br /> ❑ Tank Tie-Down Slab Insertion marks are visible and pipe is fully inserted <br /> Tank Excavation Information: Fittings are aligned properly <br /> ❑ High Water Fittings: IXTermination Fittings ❑Compression <br /> ❑ Has site ever been Contaminated/Remediated <br /> Trenching: �I Scraping of the pipe is evident <br /> 14 Excavation depth allows for 100 mm (4")bedding Pressure test results recorded <br /> 2) Bedding installed, graded, and has proper slope Secondary Containment: <br /> DO Width is sufficient to accommodate all runs of IX Pop-up indicators are out and time is marked near fit- <br /> pipe with proper spacing ting <br /> IN Minimum pipe burial depth verified <br /> Direction changes wide enough to accommodate Insertion marks are visible and pipe is fully inserted <br /> proper bend radii Fittings are aligned properly <br /> Bedding and Backfill: Scraping of the pipe is evident <br /> ❑ Clean sand [Pressure test results recorded <br /> Pea gravel <br /> ❑ Crushed stone: 3mm to 20mm (1/8"to 3/4") Ducting: <br /> Tank Sumps, Dispenser Sumps,Intermediate Sumps,Etc.: ❑Ducting installed <br /> DO Tank sumps mounted to tanks using approved ❑Ducting air test performed at 0.3 bar(5 PSI) <br /> method Installation Procedures: <br /> FFS Tank Sump: All piping runs installed with proper spacing <br /> Model#: NZA <br /> FFS Dispenser Sumpp: NIA Final Inspection: <br /> Model#: IV/H IN Air relieved from secondary containment jacket <br /> DigilWly signet by Joseph <br /> Malcolm Air relieved from primary lines <br /> 0' <br /> c=uS, <br /> Joseph Malcolm ijones"`d�o e'yGG�PYn= Back filled to grade with finish surface installed <br /> 0U.Pojw sw.nnl.mm. <br /> GN-JosephMa0—2022bg 1 Site Completion: <br /> UPP Factory Certified Installer 11 G3:49-07 <br /> ® Concrete <br /> I�pa:+e-oi oo� <br /> Print Name: Daniel Uribes ❑ Total inches over pipes 36 <br /> EI Asphalt <br /> Signature: �°" Gu `�Q0" ❑ Total inches over pipes <br /> As owner/operator I have read and comprehend the UPP warranty document FFS-0189. <br /> Print Name:-Jos'eph Malcolm 0 Franklin Fueling Systems <br /> Signature: �' /� `� ������� Date:7/15/)22 www.franklinfueling.com <br /> 3760 Marsh Road•Madison,WI 53718,U.S.A. <br /> Tel:+1 608 838 8786•Fax:+1 608 838 6433 <br /> This form must be properly completed,signed and returned to FFS no Tel:USA&Canada 1 800 225 9787•Tel:Mkxico 001 800738 7610 <br /> later than 60 days after the installation of the FFS piping products. <br /> Franklin Fueling Systems GmbH <br /> Rudolf-Diesel-Strasse 20•54516 Wittlich,GERMANY <br /> ©FFS2011 FFS-0132 Rev2 Tel:+49-6571-105-380•Fax:+49-6571-105-510 <br /> Franklin Fueling Systems,Ltd.,Olympus Close,Whitehouse Industrial Estate, <br /> Ipswich,Suffolk,IPI 5LN,UK.Tel:+44(0)1473 243300 Fax:+44(0)1473 243301 <br />