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0 <br /> Alltech,PeMB- P3541O. A-208 <br /> Sonora CA 95370 <br /> r. Ca:623541 A-Haz <br /> Compliance without Compromise Phone:209-532-7320 <br /> Fax:209-533-2650 <br /> ma i I(galltec h petro.com <br /> www.alltechpetro.com <br /> MONITORING SYSTEM CERTIFICATION <br /> A. General Information <br /> Facility Name: Costco # 038 Stockton Date of Testing/servicing: March 10, 2011 <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 Joaquon 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 Equipment Tested/Certified: <br /> Tank ID:Regular 1 Tank Tank ID:Regular 2 Tank <br /> Rin-Tank Gauging Probe. Model:Mag 1 Nln-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 /> NFill Sump Sensor(s). Model: 794380-352 ®Fill Sump Sensor(s). Model:857080-112 <br /> NElectronic Line Leak Detector. Model: PLLD NElectronic Line Leak Detector. Model: PLLD <br /> NTank Overfill/High-Level Sensor. Model:V-R Audible NTank Overfill/High-Level Sensor. Model:V-R Audible <br /> N Fillspill Bucket Tested: RPass ❑Fail N Fillspill Bucket Tested: NPass ❑Fail <br /> ❑ Fire extinguishers inspected and tagged: ❑OK ❑Not OK ❑ Fire extinguishers inspected and tagged: ❑OK❑Not OK <br /> Tank ID: Premium Tank: Tank ID:None <br /> N In-Tank Gauging Probe. Model: Mag i ❑In-Tank Gauging Probe. Model: <br /> NAnnular Space Sensor. Model:794380-301 []Annular Space Sensor. Model: <br /> NPiping Sump Sensor(s). Model:857080-112 C3 Piping Sump Sensor(s). Model: <br /> NFill Sump Sensor(s). Model:857080-112 ❑fill Sump Sensor(s). Model: <br /> NElectronic 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 <br /> ❑Fail <br /> ❑ Fire extinguishers inspected and to ed: ❑OK ❑Not OK ❑ Fire extinguishers inspected and tagged: ❑OK []Not OK <br /> Dispenser ID: 1&2 N Sump: gory❑Water❑Product Dispenser ID:3&4 R Sump: NDry❑Water❑Product <br /> E]Dispenser Containment Sensor(s). Model:794380-208 ❑Dispenser Containment Sensor(s). Model: 794380-208 <br /> ❑Shear Valve(s) (Functional test) ❑Shear Valve(s) (Functional test) <br /> ❑ Fire extinguisher inspected and tagged: ❑OK ❑Not OK ❑ Fire extin uisher inspected and tagged: ❑OK ❑Not OK <br /> Dispenser ID:5&6 N Sump: RDry❑Water[]Product Dispenser ID: 7&8 R Sump: NDry[]water[-]Product <br /> NDispenser Containment Sensor(s). Model: 794380.208 ❑Dispenser Containment Sensor(s). Model: 794380-208 <br /> NShear Valve(s) (Functional test) ❑Shear Valve(s) (Functional test) <br /> ❑ Fire extinguisher inspected and tagged: ❑OK ❑Not OK ❑ Fire extin uisher inspected and tagged: ❑OK ❑Not OK <br /> Dispenser ID:98,10 N Sump: NDry[]Water C]Product Dispenser ID: 11&12 N Sump: NDry❑Water❑Product <br /> NDispenser Containment Sensor(s). Model: 794380-208 NDispenser Containment Sensor(s).Model: 794380-208 <br /> ❑Shear Valve(s) (Functional test) ❑Shear Valve(s) (Functional test) <br /> ❑ Fire exon uisher ins ected and to ed: Kr []Not OK ❑ Fire extin uisher ins ected and to ed: ❑OK ❑Not OK <br /> Dispenser ID:Vent Stack Sump: Dry Water❑Product Dispenser ID: Sump: Dry Water Product <br /> NDispenser Containment Sensor(s). Model:794380-323 C3 Dispenser Containment Sensor(s). Model: <br /> ❑Shear Valve(s) (Functional test) []Shear Valve(s) (Functional test) <br /> ❑ Fire extinguisher inspected and tagged: ❑OK ❑Not OK ❑ Fire extinguisher inspected and tagged: ❑OK ❑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; ❑System set-up ❑Alarm history report <br /> Technician: ' <br /> '- Dr7te:19/10/11 <br /> .00 <br /> Certification: Veeder-Root 836877, Level 4 Q 4 2��� <br /> E_ ICC UST Service Technician # 8011608-UT APR <br /> SAP!JOAQUIN COUNTY <br /> FWpoNNTNTAL <br /> HEALTH DEPARTMENT <br />