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P.O.Box 4208 AlitechlPetri a, Sonora 370 Ca:623541 A-Haz Phone:209-5353 2-7-7320 Compliance without Compromise Fax:209-533-2650 mai I@al Itechpetro.com MONITORING SYSTEM CERTIFICATION www.alltechpetro.com A. General Information Facility Name: Costco # 038 Stockton Date of Testing/Servicing: March 12, 2014 Facility Address:1616 W. Hammer Lane, Stockton CA Facility Contact Person: Raj Mohan (Ser. Sta. Supervisor); Facility Phone: (209) 478-2040 LIA: San Joaquin Health; Inspector: Jeff Wong; LIA Phone: (209) 468-3448; LIA Fax: Make/Model of Monitoring System: Veeder-Root TLS-350 B. Inventory of Equipment Tested/Certified: FT�ankiD: Unleaded 87A Tank 1 Tank ID: Unleaded 87B Tank 2 nk Gauging Probe. Model: Mag 1 ®In-Tank Gauging Probe. Model: Mag 1 Annular Space Sensor. Model: 794380-301 NTank Annular Space Sensor. Model: 794380-301 g Sump Sensor(s). Model: 857080-112 NPiping Sump Sensor(s). Model: 857080-112 ump Sensor(s). Model: 794380-323 EFill Sump Sensor(s). Model: 794380-323 ump Annular Sensor. Model: 794380-304 []Fill Sump Annular Sensor. Model: 794380-304 ronic Line Leak Detector. Model: PLLD EElectronic Line Leak Detector. Model: PLLD Overfill/High-Level Sensor. Model:V-R Audible ETank Overfill/High-Level Sensor. Model:V-R Audible N Fillspill Bucket Tested: NPass []Fail N Fillspill Bucket Tested: NPass []Fail E Fire extinguishers inspected and tagged: ECK ❑Not OK N Fire extin uishers inspected and tagged: NOK❑Not OK Tank ID: Unleaded 91 Tank 3 Tank ID: Fuel Additive,Tank 4 N In-Tank Gauging Probe. Model: Mag 1 EIn-Tank Gauging Probe. Model: Mag 1 []Annular Space Sensor. Model: 794380-301 ETank Annular Space Sensor. Model: 794380-303 []Piping Sump Sensor(s). Model:857080-112 EPiping/Fill Sump Sensor(s). Model: 794380-323 EFill Sump Sensor(s). Model:794380-323 []Piping/Fill Sump Annular Sensor. Model: 794380-304 E Fill Sump Annular Sensor. Model: 794380-304 []Mechanical Line Leak Detector. Model: Fe Petro EElectronic Line Leak Detector. Model: PLLD ETank Overfill/High-Level Sensor. Model:V-R Audible NTank Overfill/High-Level Sensor. Model:V-R Audible E Fillspill Bucket Tested: NPass ❑Fail E Fillspill Bucket Tested: NPass ❑Fail N Fire extinguishers inspected and tagged: NOK ❑Not OK E Fire extinguishers inspected and tagged: NOK ❑Not OK Dispenser ID: 1&2 E Sump: NDry❑Water❑Product Dispenser ID: 3&4 E Sump: []Dry❑Water[]Product NDispenser Containment Sensor(s). Model: 794380-208 NDispenser ContainmentrSensor(s). Model:794380-208 []Shear Valve(s) (Functional test) []Shear Valve(s) (Functional test) E Fire extinguisher inspected and to ed: NOK ❑Not OK N Fire extinguisher inspected and tagged: NOK ❑Not OK Dispenser ID: 5&6 E Sump: EDry❑Water❑Product Dispenser ID: 7&8 E Sump: EDry❑Water❑Product E Dispenser Containment Sensor(s). Model: 794380-208 NDispenser Containment Sensor(s). Model: 794380-208 []Shear Valve(s) (Functional test) EShear Valve(s) (Functional test) N Fire extinguisher inspected and tagged: EOK ❑Not OK [] Fire extin uisher inspected and tagged: NOK [—]NotOK Dispenser ID: 9&10 E Sump: [D Dry❑Water El Product Dispenser ID: 11&12 E Sump: EDry❑Water E]Product E Dispenser Containment Sensor(s).Model: 794380-208 EDispenser Containment Sensor(s). Model: 794380-208 NShear Valve(s) (Functional test) NShear Valve(s) (Functional test) E Fire extinguisher inspected and tagged: ECK ❑Not OK [] Fire extinguisher inspected and tagged: EOK ❑Not OK Dispenser ID:Vent Stack E Sump:EDry❑Water❑Product Dispenser ID:Adtiv Vent E Sump:EDry❑Water❑Product ESump Containment Sensor(s). Model: 794380-323 ESump Containment Sensor(s). Model: 794380-323 ESump Annular Sensor(s). Model: 794380-304 NSump Annular Sensor(s). Model: 794380-304 E Fire exon uisher inspected and tagged: NOK ❑Not OK N Fire extinguisher inspected and tagged: EOK ❑Not OK C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports,I have also attached a copy of the report; ® System set-up ®Alarm history report Technician: Date: 3/12/14 Certification: Veeder-Root 636878, Level 4 ICC UST Service Technician #8146912-UT