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■l�+7%`/ P.O.Box 4208 Alltechfetr - , Sonora CA 95370 Ca:623541 A-Haz Phone:209-532-7-7320 Compliance without Compromise Fax:209-533-2650 mailQalltechpetro.com www.alltechpetro.co m MONITORING SYSTEM CERTIFICATION A. General Information Facility Name: Costco#658 Tracy Date of Testing/Servicing: September 25, 2012 Facility Address: 3250 W Grant Line Rd.,Tracy CA 95304 Service Station Supervisor:Troy Dominici Hut Phone: 209-834-1247 Warehouse Phone: 830-5343 LIA: San Joaquin Health; Inspector:Thuy Tran; LIA Phone: 209-468-3440; LIA Fax: 209-468-8392 Make/Model of Monitoring System: Veeder-Root TLS-350 B. Inventory of Equipment Tested/Certified: Tank ID:87 A Tank Tank ID:87 B Tank Nln-Tank Gauging Probe. Model: Mag 1 Nln-Tank Gauging Probe. Model: Mag 1 ®Annular Space Sensor. Model:794380-301 ®Annular Space Sensor. Model: 794380-301 ®Piping Sump Sensor(s). Model: 793380-352 ®Piping Sump Sensor(s). Model: 793380-352 ®Fill Sump Sensor(s). Model: 794380-352 ®Fill Sump Sensor(s). Model: 793380-352 N Electronic Line Leak Detector. Model:VR PLLD ®Electronic Line Leak Detector. Model:VR PLLD ®Tank Overfill/High-Level Sensor. Model:V-R Audible ®Tank Overfill/High-Level Sensor. Model:V-R Audible N Fillspill Bucket Tested: ®Pass ❑Fail N Fillspill Bucket Tested: ®Pass []Fail ® Fire extinguishers inspected and to ed: NOK ❑Not OK N Fire extinguishers inspected and tagged: NOK []NotOK Tank ID: 91 Tank Tank ID: None N In-Tank Gauging Probe. Model: Mag 1 ❑In-Tank Gauging Probe. Model: ®Annular Space Sensor. Model:794380-301 ❑Annular Space Sensor. Model: ®Piping Sump Sensor(s). Model: 793380-352 ❑Piping Sump Sensor(s). Model: ®Fill Sump Sensor(s). Model: 793380-208 ❑Fill Sump Sensor(s). Model: ®Electronic Line Leak Detector. Model:VR PLLD ❑ Line Leak Detector. Model: ®Tank Overfill/High-Level Sensor. Model:V-R Audible ❑Tank Overfill/High-Level Sensor. Model: N Fillspill Bucket Tested: ®Pass [-]Fail ❑ Fillspill Bucket Tested: ❑Pass ❑Fail N Fire extinguishers inspected and tagged: NOK ❑Not OK ❑ Fire extinguishers inspected and tagged: ❑OK ❑Not OK Dispenser ID: 1&2 N Sump: NDry❑Water❑Product Dispenser ID: 3&4 N Sump: NDry❑Water❑Product N Dispenser Containment Sensor(s). Model:794380-208 ®Dispenser Containment Sensor(s). Model: 794380-208 ®Shear Valve(s) (Functional test) ®Shear Valve(s) (Functional test) N Fire extinguisher inspected and tagged: NOK ❑Not OK N Fire extinguisher inspected and to ed: NOK ❑Not OK Dispenser ID: 5&6 N Sump: NDry[-]water❑Product Dispenser ID: 7&8 N Sump: NDry❑Water❑Product N Dispenser Containment Sensor(s).Model: 794380-208 ®Dispenser Containment Sensor(s). Model: 794380-208 ®Shear Valve(s) (Functional test) ®Shear Valve(s) (Functional test) N Fire extinguisher inspected and tagged: NOK ❑Not OK N Fire extinguisher inspected and tagged: NOK ❑Not OK Dispenser ID: 9&10 N Sump: NDry❑Water❑Product Dispenser ID: 11&12 N Sump: NDry❑Water[]Product N Dispenser Containment Sensor(s).Model: 794380-208 ®Dispenser Containment Sensor(s). Model: 794380-208 ®Shear Valve(s) (Functional test) ®Shear Valve(s) (Functional test) N Fire extinguisher inspected and tagged: NOK ❑Not OK N Fire extinguisher inspected and tagged: NOK ❑Not OK Dispenser ID: NONE❑ Sump: []Dry[]water❑Product Dispenser ID: NONE❑ Sump: ❑Dry[]Water❑Product F-1 Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: ❑Shear Valve(s) (Functional test) ❑Shear Valve(s) (Functional test) ❑ Fire extinguisher inspected and tagged: ❑OK ❑Not OK ❑ Fire extinguisher inspected and tagged: ❑OK ❑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: .00 Date: 9/25/12 Certification: Veeder-Root 836877, Level 4 ISD; ICC UST Service Technician # 8152115-UT.