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0 • P.O.Box 4208 <br /> All techPetr , 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 /> MONITORING SYSTEM CERTIFICATION www.alltechpetro.com <br /> A. General Information <br /> Facility Name: Costco # 038 Stockton Date of Testing/Servicing: March 3, 2016' <br /> Facility Address:1616 W. Hammer Lane, Stockton CA <br /> Facility Contact Person: Raj Mohan (Ser. Sta. Supervisor); Facility Phone: (209) 478-2040 MAR 16 2016 <br /> LIA: San Joaquin Health; Inspector: Fatinah Zareef; LIA Phone: (209) 468-3448; LIA Fax: <br /> Make/Model of Monitoring System: Veeder-Root TLS-350 ENVIRONMENTAL <br /> B. Invento of Equipment Tested/Certified: <br /> Tank ID: Unleaded 87A Tank 1 Tank ID: Unleaded 87B Tank 2 <br /> ®In-Tank Gauging Probe. Model: Mag 1 ED In-Tank Gauging Probe. Model: Mag 1 <br /> ®Tank Annular Space Sensor. Model:794380-301 ®Tank 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:794380-323 ®Fill Sump Sensor(s). Mode]:794380-323 <br /> ®Fill Sump Annular Sensor. Model:794380-304 ®Fill Sump Annular Sensor. Model:794380-304 <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 ® Fillspill Bucket Tested: ®Pass []Fail <br /> ® Fire extinguishers inspected and tagged: ®OK ❑Not OK ® Fire extinguishers inspected and tagged: ®OK❑Not OK <br /> Tank ID:Unleaded 91 Tank 3 Tank ID: Fuel Additive Tank 4 <br /> ® In-Tank Gauging Probe. Model: Mag 1 ®In-Tank Gauging Probe. Model: Mag 1 <br /> ®Annular Space Sensor. Model:794380-301 ®Tank Annular Space Sensor. Model: 794380-303 <br /> ®Piping Sump Sensor(s). Model:857080-112 ®Piping/Fill Sump Sensor(s). Model:794380-323 <br /> ®Fill Sump Sensor(s). Model: 794380-323 ®Piping/Fill Sump Annular Sensor. Model:794380.304 <br /> ®Fill Sump Annular Sensor. Model: 794380-304 ®Mechanical Line Leak Detector. Model: Fe Petro <br /> ®Electronic Line Leak Detector. Model: PLLD ®Tank Overfill/High-Level Sensor. Model:V-R Audible <br /> ®Tank Overfill/High-Level Sensor.Model:V-R Audible M Fillspill Bucket Tested: ®Pass ❑Fail <br /> ® Fillspill Bucket Tested: ®Pass ❑Fail ® Fire extinguishers inspected and tagged: ®OK ❑Not OK <br /> ® Fire extin uishers inspected and tagged: ®OK ❑Not OK <br /> Dispenser ID: 1&2 N Sump: ®Dry❑Water❑Product Dispenser ID: 3&4® Sump: ®Dry❑Water❑Product <br /> ZDispenser Containment Sensor(s). Model: 794380-208 ®Dispenser Containment Sensor(s). Model: 794380-208 <br /> ®Shear Valve(s) (Functional test) MShear Valve(s) (Functional test) <br /> ® Fire extinguisher inspected and tagged: ®OK ❑Not OK ® Fire extinguisher inspected and tagged: ®OK ❑Not OK <br /> Dispenser ID: 58,6® Sump: ®Dry❑Water❑Product Dispenser ID:7&8® Sump: ®Dry❑Water❑Product <br /> ®Dispenser Containment Sensor(s). Model:794380-208 ®Dispenser Containment Sensor(s). Model: 794380-208 <br /> ®ShearValve(s) (Functional test) OShearValve(s) (Functional test) <br /> ® Fire extinguisher inspected and tagged: ®OK ❑Not OK M Fire extin uisher inspected and tagged: ®OK ❑Not OK <br /> Dispenser ID: 9&10® Sump: ®Dry❑Water[]Product Dispenser ID: 11&12 ® Sump: ®Dry❑Water[]Product <br /> ®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 inspect and to ed: ®OK El Not OK ® Fire extin uisher ins ected and to ed: ®OK ❑Not OK <br /> Dispenser ID:Vent Stack M Sump:®Dry❑Water❑Product Dispenser ID:Adtiv Vent® Sump:®Dry❑Water❑Product <br /> ®Sump Containment Sensor(s). Model:794380.323 ®Sump Containment Sensor(s). Model: 794380-323 <br /> ®Sump Annular Sensor(s). Model:794380-304 ®Sump Annular Sensor(s). Model: 794380-304 <br /> ® Fire extinguisher inspected and to ed: ®OK ❑Not OK ® Fire extin uisher inspected and to ed: ®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 /> Date: 3/3/16 <br /> Certification: Veeder-Root 836877, Level 4 <br /> ICC UST Service Technician # 8152115-UT <br />