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Alitech <br />Complionce without Compromise <br />REdtIVEL) <br />MONITORING SYSTEM CERTIFICATIOW <br />A. Facility General Information <br />Facility Name: Costco # 1031 Manteca <br />Facility Address: 2440 Daniel St., Manteca CA <br />Facility Contact Person: Dave Zizzo (Ser. Sta. Supervisor); <br />LIA: San Joaquin Health <br />Make/Model of Monitoring System: Veeder-Root TLS -350 <br />B. Inventory of Equipment Tested/Certified: <br />Sip 4 4 W5 <br />P.O. Box 4208 <br />Sonora CA 95370 <br />Ca: 623541 A-Haz <br />Phone: 209-532-7320 <br />Fax: 209-533-2650 <br />Iltechpetro.com <br />Iltechpetro.com <br />Date of Testing: Tuesday, August 19, 2015 <br />Facility Phone: 209-824-2860 <br />Inspector: Jeff Wong. <br />Tank ID: Unleaded 87A Tank 1 <br />Tank ID: Unleaded 87B Tank 2 <br />®in -Tank Gauging Probe. Model: Mag Plus <br />Min -Tank Gauging Probe. Model: Mag Plus <br />❑Tank Annular Space Sensor. Model: 794380-303 <br />NTank Annular Space Sensor. Model: 794380-303 <br />❑ Piping Sump Sensor(s), Model: 857080-112 <br />® Piping Sump Sensor(s). Model: 857080-112 <br />®Piping Sump Annular: Model: 794380-304 <br />MPiping Sump Annular: Model: 794380-304 <br />❑Fill Sump Sensor(s). Model: 794380-323 <br />ZFill Sump Sensor(s). Model: 794380-323 <br />❑Fill Sump annular Model: 794380-304 <br />NFill Sump annular Model: 794380-304 <br />®Secondary Piping monitor Type: Vacuum <br />ZSecondary Piping monitor Type: Vacuum <br />®Electronic Line Leak Detector. Model: V -R PLLD <br />®Electronic Line Leak Detector. Model: V -R PLLD <br />❑Tank Overfill / High -Level Sensor, Model: V -R Audible <br />Tank Overfill / High -Level Sensor. Model: V -R Audible <br />N Fillspill Bucket Tested: ZPass ❑Fail <br />® Fillspill Bucket Tested: ZPass ❑Fail <br />Tank ID: Unleaded 91 Tank 3 <br />Tank ID: Fuel Additive Tank <br />® In -Tank Gauging Probe. Model: Mag Plus <br />M In -Tank Gauging Probe. Model: Mag Plus <br />®Tank Annular Space Sensor. Model: 794380-303 <br />NTank Annular Space Sensor. Model: 794380-301 <br />MPiping Sump Sensor(s). Model: 857080-112 <br />❑Piping/Fill Sump Sensor(s). Model: 794380-323 <br />®Piping Sump Annular: Model: 794380-304 <br />®Piping/Fill Sump Annular: Model: 794380-304 <br />N Fill Sump Sensor(s). Model: 794380-323 <br />®Secondary Piping monitor Type: Vacuum <br />®Fill Sump annular Model: 794380-304 <br />®Mechanical Line Leak Detector. Model: FE Petro <br />®Secondary Piping monitor Type: Vacuum <br />NTank Overfill / High -Level Sensor. Model: V -R Audible <br />Electronic Line Leak Detector. Model: PLLD <br />® Fillspill Bucket Tested: ®Pass ❑Fail <br />ZTank Overfill/ High -Level Sensor. Model: V -R Audible <br />® Fillspill Bucket Tested: MPass ❑Fail <br />Dispenser ID: 1&2 ® Sump: ZDry ❑Water ❑Product <br />Dispenser ID: 3&4 ® Sump: ZDry ❑Water ❑Product <br />0 Dispenser Containment Sensor(s). Model: 794380-323 <br />❑ Dispenser Containment Sensor(s). Model: 794380-323 <br />51 UDC Annular sensor. Model: 794380-304 <br />®* UDC Annular sensor. Model: 794380-304 <br />® Shear Valve(s) (Functional test) <br />❑ Shear Valve(s) (Functional test) <br />Dispenser ID: 5&6 ® Sump: MDry ❑Water ❑Product <br />Dispenser ID: 7&8 ® Sump: ®Dry ❑Water ❑Product <br />❑ Dispenser Containment Sensor(s). Model: 794380-323 <br />Z Dispenser Containment Sensor(s). Model: 794380-323 <br />® UDC Annular sensor. Model: 794380-304 <br />® UDC Annular sensor. Model: 794380-304 <br />ZShear Valve(s) (Functional test) <br />®Shear Valve(s) (Functional test) <br />Dispenser ID: 9&10 N Sump: ,(Dry ❑Water El Product <br />Dispenser ID: 11&12 ® Sump: ®Dry ❑Water ❑Product <br />® Dispenser Containment Sensor(s). Model: 794380-323 <br />M Dispenser Containment Sensor(s). Model: 794380-323 <br />❑ UDC Annular sensor. Model: 794380-304 <br />Z UDC Annular sensor. Model: 794380-304 <br />❑Shear Valve(s) (Functional test) <br />❑Shear Valve(s) (Functional test) <br />Dispenser ID: 13&14 N Sump: ZDry ❑Water ❑Product <br />Dispenser ID: 15&16 ® Sump: ZDry ❑Water ❑Product <br />Dispenser Containment Sensor(s). Model: 794380-323 <br />❑ Dispenser Containment Sensor(s), Model: 794380-323 <br />® UDC Annular sensor. Model: 794380-304 <br />❑ UDC Annular sensor. Model: 794380-304 <br />Shear Valve(s) (Functional test) <br />® Shear Valve(s) (Functional test) <br />Dispenser ID: Vent Stack Transition Sump <br />Dispenser ID: Additive Tank Vent Sump <br />N Sump: ®Dry ❑Water ❑Product <br />N Sump: ®Dry []Water ❑Product <br />Z UDC Sump Containment Sensor(s). Model 794380-323 <br />® UDC Sump Containment Sensor(s), Model: 794380-323 <br />® UDC Sump Annular sensor. Model: 794380-304 <br />® UDC Sump Annular sensor. Model: 794380-304 <br />* Sensor installed but not operating properly. <br />Technician: _:P� <br />Certification: Veeder-Root B36878, Level 4 <br />ICC UST Service Technician # 8146912 -UT <br />Date: 8/19/15 <br />