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MONIYORING SYSTEM CERTIFI"TION For Use By All Jurisdictions Within the State ofCalijornia Authority Cited: Chapter 6.7, Health and Safety Code:Chapter 16,Divisiun 3, Title 23, California Code of Regulations Itis form mast be used to document testing and servicing of monitoring equipttrrtr. A separate certification or renOtt mint be oripared for tsch monitoring system control ponel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of(his forth to the local agency regulating UST systems within 30 days of test date. A. General Information FacilityName: COSTCO 9656 Bldg,No.: Site Address: 3520 W(MANTLINE RD City: TRACY Zip: 95377 Facility Contact Person:_ROBERT Contact Phone No.: 209-834-1247 Make/Model of Monitoring System: VEEDER ROOT TLS350 Date of Testing/Servicing: 9/30/06 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicates inc rquljo2col ins red/serviced Task ID'. 87-1 Taark @: 87-2 X In-Tank Gauging Pmbc Model 8 4 7 39 01 07 X In-Tank Gauging Robe. Model: 847390407 X Annular Spare or Vault Sensor Mode: 794390.302 X Annular Space or Vault Sensor, Model: 794390.302 X Piping Sump/Trench Seasons). Model: 794380-362 X Piping Sump/Trench Sensons). Mode: 794380362 X 1-111 Sump Semor(s), Modd: 794380-362 X Fill Sump Sensons). Mkdd: 794380-352 X Mechanical line 1 tale Ducctnr Model 116-035 X Mechanical Litz`leak Detector. Model. 116-435 ❑Electronic Line Lcak Detector. Model: ❑Electronic Line Leak fktector Madel: X Tank Overfill I High-level Scums. Model: 790087-001 X Tank(T¢�11 t High-Level Sensor. Model: 780091-M ❑Crater(specify equipment type and model in Section F on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: 91 Tank ID: X In-Tani:Gauging Probe. Model. 847390707 ❑In-Tank Gauging Probe. Model: .X .Annular Space m Vault ticirwr. Model: 784390.302 ❑Annular Space or Vault Sensor. Model X Piping Sump/Trench Sen", s) Model'. 794380362 ❑Piping Sump/Trench Scainnsi. Model: X Fill Sump Sensor(s). Medd. 794380352 ❑Fill Sump Senwris) Model. - X Mechanical Line Leak Detector. Model: 99LD2000 ❑Mechanical Linc Leak Detector Model: ❑Electronic Lint Leak Deteesor. Model: ❑Electronic Line Leak Detector. Model: X Tank Ovehll/High-Level Sensor. Mode: 790091-Ml ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model bisection E on Page 2). ❑Other(specify equipment type and model in Section E an Page 2), Dispenser ID: 1&2 Dispenser ID: 38A X Disposer Cunainn"t Scn".,). Mudd. 794380208 X ni%mmer Cnnminmam Sensmist. Model 794380-208 X Shear Valve(s), X Shear VaNc(h). ❑Dispenwr Containment Floar(s)and C'hanas). pe Mardis)and Chorus). ❑Din ase Containment Floa Dispenser ID 5&6 Dispenser 10: 7&8 X ttsprnserConteinment lernor(s). Model: 704390208 X Dispenses Containment Seasons), Model: 794380208 X Shear Vaive(sl X Shea Vatve(sl. ❑Dispense Containment Moat($)and Chain(s). ❑Dispenser Containment Flotu(s)and Chan ds). Dispenser ID: 9&10 Dispenser ID: 11&12 X Dispenur ContainmesuScnsm 1. Mndel 794380-206 X Dispenser Containment Seasons). Model: 794380-208 X Shear\'aNt(sl. X Shear Valvets). ❑Dispenser Containment Fluent)and Chasms). ❑Dispenxr Containment Flonts)and Charms). •If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility C. Certification -I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to Ibis Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plan showing the layout of monitoring equipment For any equipment capable of generating nuc 1 have also attached a copy of the report;(ehec4 elf thin apply): X System set-up. X-A ar a /report Technician Name roti PATRICK MULHALL { (� 1 Sigtlatu C B33136 45340 Testing Company Name: B.Z Service Station Malntenanee Phone No.:(916) 371-2360 Site Address: 630 Houston Street West Sacramento,CA 95691 Date of Testing/Servicing: 8f30108 Page 1 of 3 DN#34-1/4 r w.umdm,,,rg Rev.01/26/16