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C REEIVE P.O.eox 4208 Sonora CA 95370 Or O.,T Ca:623541 AAlitechlPetrZ= -Hoz 9 2u 1 07 Phone:209-532-7320 , Compliance without Compromise Fax:209-533-2650 ENVIRONMENTAL mail@alltechpetro.com ". -,r• hF www.ailtechpetro.com MONITORING SYSTEM CERTIF[C�AN A. General Information Facility Name: Costco #658 Tracy Date of Testing/Servicing: September 21, 2017 Facility Address: 3250 W Grant Line Rd., Tracy CA 95304 Service Station Supervisor: Tony Haggard Hut Phone: 209-834-1247 Warehouse Phone: 830-5343 LIA: San Joaquin Health; Inspector: John Alaniz; LIA Phone: 209-468-3440; email: jalanizl @sjcehd.com Make/Model of Monitoring System: Veeder-Root TLS-350 B. Inventory of Equipment Tested/Certified: Tank ID:Tank 1 Unleaded 87A Tank ID:Tank 2 Unleaded 87B N In-Tank Gauging Probe. Model: Mag 1 N In-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 N Fill Sump Sensor(s). Model: 794380-352 N Fill Sump Sensor(s). Model: 793380-352 ❑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: Wass ❑Fail N Fire extinguishers inspected and tagged: NOK [:]NotOK N Fire extin uishers inspected and tagged: NOK ❑Not OK Tank ID:Tank 3 Unleaded 91 Tank ID:Tank 4 Additive Tank N In-Tank Gauging Probe. Model: Mag 1 Nin-Tank Gauging Probe. Model: Mag Plus ❑Annular Space Sensor. Model: 794380-301 ❑Annular Space Sensor. Model: 794380-303 ❑Piping Sump Sensor(s). Model: 793380-352 ®Piping/Fill Sump Sensor(s). Model: 793380-323 N Fill Sump Sensor(s). Model: 793380-208 N Fill Sump annular. Model: 794380-304 ®Electronic Line Leak Detector. Model:VR PLLD ®Mechanical Line Leak Detector. Model: Fe Petro ❑Tank Overfill/High-Level Sensor. Model:V-R Audible ®Tank Overfill/High-Level Sensor. Madel:V-R Audible N Fillspill Bucket Tested: ❑Pass ❑Fail N Fillspill Bucket Tested: ®Pass ❑Fail N Fire extinguishers inspected and to ed: NOK ❑Not OK N Fire extinguishers inspected and tagged: NOK ❑Not OK Dispenser ID: 1&2 N Sump: ❑Dry❑Water❑Product Dispenser ID: 3&4 N Sump: ®Dry❑Water ❑Product ®Dispenser Containment Sensor(s). Model: 794380-208 N Dispenser Containment Sensor(s). Model: 794380-208 NShear Valve(s) (Functional test) ❑Shear Valves) (Functional test) N Fire extinguisher inspected and tagged: NOK ❑Not OK N Fire extinguisher inspected and tagged: NOK ❑Not OK Dispenser ID: 5&6 N Sump: NDry❑Water❑Product Dispenser ID: 7&8 N Sump: ®Dry❑Water❑Product N Dispenser Containment Sensor(s). Model: 794380-208 N Dispenser Containment Sensor(s). Model:794380-208 NShear Valve(s) (Functional test) NShear Valve(s) (Functional test) N Fire extinguisher inspected and tagged: NOK ❑Not OK ® Fire extinguisher inspected and tagged: NOK ❑Not OK Dispenser ID: 9&10 N Sump: NDry❑Water El Product Dispenser ID: 11&12 N Sump: ®Dry❑Water❑Product ❑Dispenser Containment Sensor(s). Model: 794380-208 ®Dispenser Containment Sensor(s). Model: 794380-208 NShear Valves) (Functional test) NShear Valve(s) (Functional test) N Fire extinguisher inspected and tagged: NOK ❑Not OK N Fire extinguisher inspected and tagged: NOK ❑Not OK Dispenser ID: Vent Box N Sump: ®Dry❑Water ❑Product Dispenser ID: ❑ Sump: ❑Dry ❑Water❑Product N Dispenser Containment Sensor(s). Model: 793380-323 ❑Dispenser Containment Sensor(s). Model: ® UDC Annular Space Sensor. Model: 794380-304 ❑Shear Valves) (Functional test) ® Fire extinguisher inspected and tagged: NOK ❑Nat 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: Date: 09/21/17 Certification: Veeder-Root 1336878, Level 4 ISD; iCC UST Service Technician # 8146912-UT.