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i AlItech Petro Inc. • 17759 Buttercup Circle, Sonora, CA 95370 Phone: 209-532-7320; Fax: 209-533-2650 California Contractor 623541 A-Haz alltechmailC>,me. corn MONITORING SYSTEM CERTIFICATION for ELD SYSTEMS A. Facility General Information Facility Name: Costco # 1031 Manteca Date of Testing: Tuesday, August 18, 2009 Facility Address: 2440 Daniel St., Manteca CA Facility Contact Person: Julian Ochoa (Ser. Sta. Supervisor); Facility Phone: LIA: San Jaoquin Health; Inspector: Michelle Henry. Make/Model of Monitoring System: Veeder-Root TLS -350 u 3. Inv to of E ui ment Tested/Certified: Tank ID: Regular l Tank Tank 1D: Regular 2 Tank ® In -Tank Gauging Probe. Model: Mag Plus 0 in -Tank Gauging Probe. Model: Mag Plus ❑ Tank Annular Space Sensor. Model: 794380-301 ❑ Tank Annular Space Sensor. Model: 794380-301 ❑ Piping Sump Sensor(s). Model: 857080-112 ® Piping Sump Sensor(s). Model: 857080-112 ®Piping Sump Annular: Model: 794380-304 ❑Piping Sump Annular: Model: 794380-304 ® Fill Sump Sensor(s). Model: 857080-112 ® Fill Sump Sensor(s). Model: 857080-112 ®Fill Sump annular Model: 794380-304 ®Fill Sump annular Model: 794380-304 ®Secondary Piping monitor Type: Vacuum ®Secondary Piping monitor Type: Vacuum Elecrtonic Line Leak Detector. Model: PLLD ® Electronic Line Leak Detector. Model: PLLD ® Tank Overfill / High -Level Sensor. Model: V -R Audible ❑ Tank Overfill / High -Level Sensor. Model: V -R Audible ® Fills ill Bucket Tested: (Vapor Bucket Failed Pass ❑Fail ❑ Fills ill Bucket Tested: ®Pass ❑Fail Tank ID: Premium Tank Tank ID: • In -Tank Gauging Probe. Model: Mag Plus ❑ In -Tank Gauging Probe. Model: • Tank Annular Space Sensor. Model: 794380-301 ❑ Tank Annular Space Sensor_ Model: • Piping Sump Sensor(s). Model: 857080-112 ❑ Piping Sump Sensor(s). Model: I@Piping Sump Annular: Model: 794380-304 ❑Piping Sump Annular: Model: 0 Fill Sump Sensor(s). Model: 857080-112 ❑ Fill Sump Sensor(s). Model: ®Fill Sump annular Model: 794380-304 []Fill Sump annular Model: (Secondary Piping monitor Type: Vacuum ❑Secondary Piping monitor Type: ❑ Electronic Line Leak Detector. Model: PLLD ❑ Line Leak Detector. Model • Tank Overfill 1 High -Level Sensor. Model: V -R Audible ❑ Tank Overfill / High -Level Sensor. Model: ❑ Fills ill Bucket Tested: ®Pass ❑Fail ❑ Fills ill Bucket Tested: ❑Puss ❑Fail Dispenser ID: 1&2 ® Sump: EDry []Water [I Product Dispenser ID: 3&4 ❑ Sump: ®Dry ❑Water ❑Product ® Dispenser Containment Sensor(s). Model: 794380-323 ® Dispenser Containment Sensor(s). Model: 794380-323 UDC Annular sensor. Model: 794380-304 ® UDC Annular sensor. Model: 794380-304 ® Shear Valve(s) (Functional test) ® Shear Vaive(s) (Functional test) Dispenser ID: 5&6 0 Sump: ZDry ❑Water ❑Product Dispenser ID: 7&8 ❑ Sump: RDry ❑Water ❑Product ❑ Dispenser Containment Sensor(s). Model: 794380-323 0 Dispenser Containment Sensor(s). Model: 794380-323 UDC Annular sensor Model: 794380-304 0 UDC Annular sensor. Model: 794380-304 ® Shear Valve(s) Functional test ® Shear Valve(s) (Functional test) Dispenser ID: 9&10 ® Sump: ❑Dry []Water ❑Product Dispenser ID: II&12 U Sump: NDry ❑Water ❑Product ® Dispenser Containment Sensor(s). Model: 794380-323 ® Dispenser Containment Senso0s). Model: 794380-323 ❑ UDC Annular sensor. Model: 794380-304 0 UDC Annular sensor. Model: 794380-304 ® Shear Valve(s) (Functionai test) ® Shear Valve(s) Functional test) Dispenser ID: 13&14 ❑ Sump: ®Dry ❑Water ❑Product Dispenser ID: 15&16 ❑ Sump: ❑Dry ❑Water ❑Product ® Dispenser Containment Sensor(s). Model 794380-323 0 Dispenser Containment Sensor(s). Model: 794380-323 ® UDC Annular sensor. Model: 794380-304 10 UDC Annular sensor. Model: 794380-304 ® Shear Valve(s) Functional test) 0 Shear Valves Functional test) Dispenser ID: Fent Stack Transition Sump Dispenser ID: ❑ Sump: ❑Dry []Water ❑Product ® Sump: EDry ❑V4'ater ❑Product ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 794380-323 ❑ UDC Annular sensor. Model: ® UDC Annular sensor Model: 794380-304 Technician: �P� Certification: Veeder-Root B36878, Level 2/3 ICC UST Service Technician # 8005930 -UT Date: 8/18/09