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,% P.O.Box 4208 <br /> AfftechiPetri , Sonora 370 <br /> Ca:623541 A-Haz <br /> Phone:209-5353 2-7-7320 <br /> Compliance without Compromise Fax:209-533-2650 <br /> mail@alltechpetro.com <br /> www.a lltech petro.com <br /> MONITORING SYSTEM CERTIFICATION <br /> A. General Information <br /> Facility Name: Costco # 038 Stockton Date of Testing/Servicing: March 14, 2013 <br /> Facility Address:1616 W. Hammer Lane, Stockton CA <br /> Facility Contact Person: Rick Medeiros (Ser. Sta. Supervisor); Facility Phone: (209) 478-2040 <br /> LIA: San Joaquin Health; Inspector: Garrett Backus; LIA Phone: (209) 468-3448; LIA Fax: <br /> Make/Model of Monitoring System: Veeder-Root TLS-350 <br /> B. Inventory of E uipment Tested/Certified: <br /> Tank ID: Unleaded 87 Tank 1 Tank ID: Unleaded 87 Tank 1 <br /> [A In-Tank Gauging Probe. Model: Mag 1 ®In-Tank Gauging Probe. Model: Mag 1 <br /> ®Annular Space Sensor. Model: 794380-301 ®Annular Space Sensor. Model: 794380-301 <br /> ®Piping Sump Sensor(s). Model: 857080-112 ®Piping Sump Sensor(s). Model:857080-112 <br /> ®Fill Sump Sensor(s). Model: 794380-352 ®Fill Sump Sensor(s). Model:857080-112 <br /> ®Electronic Line Leak Detector. Model: PLLD ®Electronic Line Leak Detector. Model: PLLD <br /> ®Tank Overfill/High-Level Sensor. Model:V-R Audible ®Tank Overfill/High-Level Sensor. Model:V-R Audible <br /> ® Fillspill Bucket Tested: ®Pass ❑Fail E Fillspill Bucket Tested: ®Pass ❑Fail <br /> ® Fire extinguishers inspected and tagged: NOK ❑Not OK E Fire extinguishers inspected and tagged: NOK❑Not OK <br /> Tank ID: Unleaded 91 Tank 3 Tank ID: None <br /> N In-Tank Gauging Probe. Model: Mag 1 ❑In-Tank Gauging Probe. Model: <br /> NAnnular Space Sensor. Model: 794380-301 ❑Annular Space Sensor. Model: <br /> ❑Piping Sump Sensor(s). Model:857080-112 ❑Piping Sump Sensor(s). Model: <br /> NFill Sump Sensor(s). Model:857080-112 ❑Fill Sump Sensor(s). Model: <br /> E Electronic Line Leak Detector. Model: PLLD ❑ Line Leak Detector. Model: <br /> NTank Overfill/High-Level Sensor. Model:V-R Audible ❑Tank Overfill/High-Level Sensor. Model: <br /> N Fillspill Bucket Tested: NPass []Fail ❑ Fillspill Bucket Tested: ❑Pass ❑Fail <br /> N Fire extinguishers inspected and tagged: NOK ❑Not OK ❑ Fire extinguishers inspected and tagged: [:]OK ❑Not OK <br /> Dispenser ID: 1&2 E Sump: EDry❑Water❑Product Dispenser ID: 3&4 E Sump: EDry❑Water❑Product <br /> NDispenser Containment Sensor(s). Model: 794380-208 NDispenser Containment Sensor(s). Model: 794380-208 <br /> EShear Valve(s) (Functional test) NShear Valve(s) (Functional test) <br /> E Fire exon uisher ins ected and tagged: NOK ❑Not OK E Fire extinguisher ins ected and tagged: NOK ❑Nat OK <br /> Dispenser ID: 5&6 E Sump: NDry❑Water❑Product Dispenser ID: 7&8 E Sump: NDry❑Water❑Product <br /> NDispenser Containment Sensor(s). Model: 794380-208 NDispenser Containment Sensor(s). Model: 794380-208 <br /> EShear Valve(s) (Functional test) NShear Valve(s) (Functional test) <br /> E Fire extinguisher inspected and tagged: NOK ❑Not OK N Fire extinguisher inspected and tagged: EOK []NotOK <br /> Dispenser ID: 9&10 E Sump: NDry[]Water❑Product Dispenser ID: 11&12 N Sump: EDry❑Water❑Product <br /> NDispenser Containment Sensor(s). Model: 794380-208 NDispenser Containment Sensor(s). Model: 794380-208 <br /> EShear Valve's) (Functional test) EShear Valve(s) (Functional test) <br /> E Fire extin uisher inspected and tagged: NOK ❑Not OK N Fire extin uisher inspected and tagged: ECK ❑Not OK <br /> C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' <br /> guidelines. Attached to this Certification is a Plot Plan showing the layout of monitoring equipment. For any equipment capable of <br /> generating such reports,I have also attached a copy of the report; M System set-up ®Alarm history report <br /> Technician: Date: 03/14/13 <br /> Certification: Veeder-Root B36878, Level 4 <br /> ICC UST Service Technician # 8146912-UT <br />