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0 UST System Impact Valve Testing WSJ OL F AUG 2 52016 Location Name: Costco #1031 Manteca Date: 8/18196 Address: 2440 Daniel St. City: Manteca State: Ca Dispenser Number Product Grade Impact Valve Secure? Impact Valve Locks? Test Result Comments 1-2 87 Eyes [:]No ZYes [_]No ZPass ❑ Fail 1-2 91 Eyes ❑No Eyes [:]No EPass ❑ Fail 3-4 87 EYes [-]No ZYes ❑No EPass ❑ Fail 3-4 91 ®Yes ❑No EYes ❑No ®Pass ❑ Fail 5-6 87 Eyes ❑No ZYes ❑No ®Pass ❑ Fail 5-6 91 ®Yes [:]No ®Yes ❑No ®Pass ❑ Fail 7-8 87 ®Yes ❑No ®Yes [:]No ®Pass ❑ Fail 7-8 91 ®Yes ❑No ®Yes ❑No XPass ❑ Fail 9-10 87 ®Yes ❑No ®Yes [:]No ®Pass ❑ Fail 9-10 91 Eyes ❑No ®Yes ❑No ZPass ❑ Fail 11-12 87 ®Yes [:]No ®Yes [-]No ®Pass ❑ Fail 11-12 91 NYes [:]No Eyes ❑No ®Pass ❑ Fail 13-14 S7 EYes [:]No nYes [:]No 0Pass ❑ Fail 13-14 91 ®Yes ❑No HYes ❑No ZPass ❑ Fail 15-16 87 EYes [:]No Eyes [:]No ®Pass ❑ Fail 15-16 91 Eyes ❑No ®Yes ❑No MPass ❑ Fail ❑Yes ❑No ❑Yes ❑No ❑Pass ❑ Fail ❑Yes ❑No ❑Yes ❑No ❑Pass ❑ Fail [-]Yes ❑No ❑Yes ❑No ❑Pass ❑ Fail ❑Yes ❑No ❑Yes ❑No ❑Pass ❑ Fail ❑Yes ❑No ❑Yes ❑No ❑Pass ❑ Fail ❑Yes ❑No ❑Yes ❑No ❑Pass ❑ Fail ❑Yes ❑No [7]Yes ❑No ❑Pass ❑ Fail ❑Yes [:]No ❑Yes ❑No L] Pass ❑ Fail Dyes ❑No Eyes ❑No ❑Pass ❑ Fail [-]Yes [_]No ❑Yes [:]No ❑Pass ❑ Fail ❑Yes [:]No ❑Yes ❑No ❑Pass ❑ Fail ❑Yes ❑No ❑Yes [:]No ❑Pass ❑ Fail ❑Yes ❑No ❑Yes [:]No ❑Pass ❑ Fail Dyes [-]No ❑Yes ❑No ❑Pass ❑ Fail Revised 11/03/2014