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995 Blue Gentian Rd - Gas Station Tank Line Testing & Certification Results 2019-11-12Testing and Inspection Certificate Tanknology Inc. 11000 North MoPac Expressway, Suite 500, Austin, TX 78759 800-800-4633 www.tanknology.com Page 1 of 2 Test Date 11/4/2019 Tanknology WO#MW3-6365789 Test Purpose POST CONST Customer PO#CONTRACT #17-0406-02 Customer Location COSTCO WHOLESALE C/O MG2 Vendor #9823-00/20010025 1101 Second Ave, Suite 100 Seattle, WA 98101 Costco #1363 Eagan (1363 Eagan) 995 Blue Gentian Drive Eagan, MN 55121 Attn: PROJECT MANAGER Attn: (206) 962-6500 () Test / Inspection Description Item Tested Date Tested Result Precision Tank Tightness Tank 3 PREMIUM 11/4/2019 Pass Precision Tank Tightness Tank 2 UNLEADED 11/4/2019 Pass Precision Tank Tightness Tank 4 UltraZol 9888 11/4/2019 Pass Precision Tank Tightness Tank 1 UNLEADED 11/4/2019 Pass Precision Line Tightness (.1 GPH) Tank 1 Line 1 UNLEADED 11/4/2019 Pass Precision Line Tightness (.1 GPH) Tank 2 Line 1 UNLEADED 11/4/2019 Pass Precision Line Tightness (.1 GPH) Tank 3 Line 1 PREMIUM 11/4/2019 Pass Precision Line Tightness (.1 GPH) Tank 4 Line 1 UltraZol 9888 11/4/2019 Pass Line Leak Detector (3 GPH) Tank 1 Line 1 UNLEADED 11/4/2019 Pass Line Leak Detector (3 GPH) Tank 2 Line 1 UNLEADED 11/4/2019 Pass Line Leak Detector (3 GPH) Tank 3 Line 1 PREMIUM 11/4/2019 Pass Line Leak Detector (3 GPH) Tank 4 Line 1 UltraZol 9888 11/4/2019 Pass Impact Valve Inspection See test report for details 11/4/2019 Pass Leak Detection Monitoring System Inspection See test report for details 11/4/2019 Pass Spill Containment / Bucket Testing Tank 1 UNLEADED SB 1 - Fill - Direct 11/4/2019 Pass Spill Containment / Bucket Testing Tank 1 UNLEADED SB 1 - Vapor - Direct 11/4/2019 Pass Spill Containment / Bucket Testing Tank 2 UNLEADED SB 1 - Fill - Direct 11/4/2019 Pass Spill Containment / Bucket Testing Tank 2 UNLEADED SB 1 - Vapor - Direct 11/4/2019 Pass Spill Containment / Bucket Testing Tank 3 PREMIUM SB 1 - Fill - Direct 11/4/2019 Pass Spill Containment / Bucket Testing Tank 3 PREMIUM SB 1 - Vapor - Direct 11/4/2019 Pass Spill Containment / Bucket Testing Tank 4 UltraZol 9888 SB 1 - Fill - Direct 11/4/2019 Pass Spill Containment / Bucket Testing Tank 4 UltraZol 9888 SB 1 - Vapor - Direct 11/4/2019 Pass Stage I Pressure Decay See test report for details 11/4/2019 Pass Pressure Vacuum Vent Cap See test report for details 11/4/2019 Pass Stage 1 Vapor Recovery Survey See test report for details 11/4/2019 Complete Torque Test Tank 1 - P 11/4/2019 Pass Torque Test Tank 1 - V 11/4/2019 Pass Tanknology Representative: Derrick Jungers Technician: Dylan Brant Telephone: (507) 455-1200 Technician Certification: (See forms) Testing and Inspection Certificate Tanknology Inc. 11000 North MoPac Expressway, Suite 500, Austin, TX 78759 800-800-4633 www.tanknology.com Page 2 of 2 Test Date 11/4/2019 Tanknology WO#MW3-6365789 Test Purpose POST CONST Customer PO#CONTRACT #17-0406-02 Customer Location COSTCO WHOLESALE C/O MG2 Vendor #9823-00/20010025 1101 Second Ave, Suite 100 Seattle, WA 98101 Costco #1363 Eagan (1363 Eagan) 995 Blue Gentian Drive Eagan, MN 55121 Attn: PROJECT MANAGER Attn: (206) 962-6500 () Test / Inspection Description Item Tested Date Tested Result Torque Test Tank 2 - P 11/4/2019 Pass Torque Test Tank 2 - V 11/4/2019 Pass Torque Test Tank 3 - P 11/4/2019 Pass Torque Test Tank 3 - V 11/4/2019 Pass Torque Test Tank 4 - P 11/4/2019 Pass Torque Test Tank 4 - V 11/4/2019 Pass Overfill Insp OPW Flapper Valve 1 UNLEADED 11/4/2019 Pass Overfill Insp OPW Flapper Valve 2 UNLEADED 11/4/2019 Pass Overfill Insp OPW Flapper Valve 3 PREMIUM 11/4/2019 Pass Overfill Insp OPW Flapper Valve 4 UltraZol 9888 11/4/2019 Pass Overfill Alarm Operation Inspection 1 UNLEADED 11/4/2019 Pass Overfill Alarm Operation Inspection 2 UNLEADED 11/4/2019 Pass Overfill Alarm Operation Inspection 3 PREMIUM 11/4/2019 Pass Overfill Alarm Operation Inspection 4 UltraZol 9888 11/4/2019 Pass E-Stop Inspection See test report for details 11/4/2019 Pass Costco Annual Sump Inspection See report for details 11/4/2019 Pass Tanknology Representative: Derrick Jungers Technician: Dylan Brant Telephone: (507) 455-1200 Technician Certification: (See forms) VacuTect Tank Tightness Test page 1 of 1 Work Order:6365789 Date:11/4/2019 Site Name/ID:Costco #1363 Eagan Address:995 Blue Gentian Drive City:Eagan State:MN Zip:55121 Tank Information Customer Tank ID Regulatory Tank ID Product Category Product Name Gallons Capacity Tank Type Tank Walls Compartmentalized Siphon Tank Vents included with test Test Start Time Test End Time Water ingress (Y/N) Bubble ingress (Y/N) Ullage ingress (Y/N) Test Result (P/F/I) 3 PREMIUM 3 Gasoline - Premium PREMIUM 40000 Fiberglass Doublewall (factory) No No with other tank 10:30:00 11:45:00 No No No Pass 2 UNLEADED 2 Gasoline - Regular UNLEADED 40000 Fiberglass Doublewall (factory) No Yes with other tank 12:30:00 14:00:00 No No No Pass 4 UltraZol 9888 4 Other UltraZol 9888 1500 Fiberglass Doublewall (factory) No No with this tank 10:00:00 12:00:00 No No No Pass 1 UNLEADED 1 Gasoline - Regular UNLEADED 40000 Fiberglass Doublewall (factory) No Yes with this tank 12:30:00 14:00:00 No No No Pass Yes No diagnostic only - Test was performed per 3rd party certifications as specified in 40 CFR parts 280 and 281. Technician Comments : UNL A tank was tested with entire manifolded vent line, UNL B and PREM were tested with extraction plugs in vapor recovery riser to isolate vent from tank. Sump manway bolts, vapor recovery risers and fill risers all needed to be tightened to stop ullage ingress. Technician Name Dylan Brant Certification #138148 Technician Signature Environmental Compliance for Petroleum Systems ©2019 Tanknology Inc., Austin,TX. All rights reserved. tanknology.com Product Line Tightness Test Page 1 of 1 Work Order: 6365789 Date: 11/4/2019 Site Name/ID: Costco #1363 Eagan / 1363 Eagan Address: 995 Blue Gentian Drive City: Eagan State: MN Zip: 55121 Tank Information Test Method Customer Tank ID Product Name Delivery Type Test Pressure Test Start Time Test End Time Final Leak Rate Test Result(P/F/I) Test was performed per 3rd party certifications as specified in 40 CFR parts 280 and 281 Tank # 1 Line # 1 TLD-1 1 UNLEADED Pressure 65 14:45 15:45 -0.01 Pass Yes Tank # 2 Line # 1 TLD-1 2 UNLEADED Pressure 65 15:30 16:30 -0.01 Pass Yes Tank # 3 Line # 1 TLD-1 3 PREMIUM Pressure 65 19:45 20:45 -0.01 Pass Yes Tank # 4 Line # 1 TLD-1 4 UltraZol 9888 Pressure 65 10:34 11:34 0.00 Pass Yes Tank # Line # Tank # Line # Technician Comments: - UNL A line found leak under disp 9-10, pipe was tightened - UNL B line found leak at STP sump, pipe was tightened - PREM line leak was found at STP sump, fittings were tightened Technician Name:Dylan Brant Certification #:138142 exp: 12/16/2020 Technician Signature: Environmental Compliance for Petroleum Systems ©2019 Tanknology Inc., Austin, TX. All rights reserved. tanknology.com LDT 5000 Field Test Apparatus Line Leak Detector Test Page 1 of 1 Work Order:6365789 Date:11/4/2019 Site Name / ID:Costco #1363 Eagan / 1363 Eagan Address:995 Blue Gentian Drive City:Eagan State:MN Zip:55121 Tank ID Product Product Line Tested From Existing/New Mechanical/Electronic Manufacturer/Model Serial No. Pump Operating Pressure (psi) Calibrated Leak (ml/min) Calibrated Leak (gph) Holding PSI *N/A for Electronic LD's Resiliency (ml) *N/A for Electronic LD's Metering PSI *N/A for Electronic LD's Opening Time (sec) *N/A for Electronic LD's Test Results 1 UNLEADED 1 19 Existing Electronic Veeder Root DPLLD 41.00 189.0 3.00 Pass 2 UNLEADED 1 22 Existing Electronic Veeder Root DPLLD 42.00 189.0 3.00 Pass 3 PREMIUM 1 19 Existing Electronic Veeder Root DPLLD 42.00 189.0 3.00 Pass 4 UltraZol 9888 1 Existing Electronic Veeder Root DPLLD 36.00 189.0 3.00 Pass Technician Comments: Technician Name:Dylan Brant Certification #:138137 Technician Signature:Expire Date:12/16/2020 Environmental Compliance for Petroleum Systems © 2019 Tanknology Inc., Austin, TX. All rights reserved. tanknology.com Impact Valve Inspection Impact Valve Operational Inspection Work Order:6365789 Date:11/4/2019 Site Name/ID:Costco #1363 Eagan Address:995 Blue Gentian Drive City:Eagan State:MN Zip:55121 How Inspected: Line Test NFPA 30A PEI RP1200 Other ind standard Dispenser Number Grade Secure Mount? Valve Lock?Pass/ Fail Comments 1/2 87 Pass Fail Not Tested 1/2 91 Pass Fail Not Tested 3/4 87 Pass Fail Not Tested 3/4 91 Pass Fail Not Tested 5/6 87 Pass Fail Not Tested 5/6 91 Pass Fail Not Tested 7/8 87 Pass Fail Not Tested 7/8 91 Pass Fail Not Tested 9/10 87 Pass Fail Not Tested 9/10 91 Pass Fail Not Tested 11/12 87 Pass Fail Not Tested 11/12 91 Pass Fail Not Tested 13/14 87 Pass Fail Not Tested 13/14 91 Pass Fail Not Tested 15/16 87 Pass Fail Not Tested 15/16 91 Pass Fail Not Tested 17/18 87 Pass Fail Not Tested 17/18 91 Pass Fail Not Tested 19/20 87 Pass Fail Not Tested 19/20 91 Pass Fail Not Tested Technician Comments: Technician Name:Dylan Brant Signature: Environmental Compliance for Petroleum Systems ©2019 Tanknology Inc., Austin, TX. All rights reserved. tanknology.com Impact Valve Inspection Impact Valve Operational Inspection Work Order:6365789 Date:11/4/2019 Site Name/ID:Costco #1363 Eagan Address:995 Blue Gentian Drive City:Eagan State:MN Zip:55121 Dispenser Number Grade Secure Mount? Valve Lock?Pass/ Fail Comments 21/22 87 Pass Fail Not Tested 21/22 91 Pass Fail Not Tested 23/24 87 Pass Fail Not Tested 23/24 91 Pass Fail Not Tested Technician Comments: Technician Name:Dylan Brant Signature: Environmental Compliance for Petroleum Systems ©2019 Tanknology Inc., Austin, TX. All rights reserved. tanknology.com MONITORING SYSTEM CERTIFICATION This form is used to document testing and servicing of tank and piping leak monitoring equipment. If required by applicable law, a copy of the completed form must be provided by the Testing Contractor or owner to the governing UST agency as required by regulation. A. General Information Facility Name:Costco #1363 Eagan Bldg. No.: Site Address:995 Blue Gentian Drive City:Eagan State:MN Zip:55121 Facility Contact Person:Contact Phone No.:- Make/Model of Monitoring System:Veeder Root TLS-450 PLUS Date of Testing/Servicing:11/4/2019 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID:1 - UNLEADED In-Tank Gauging Probe.Model:mag Annular Space or Vault Sensor.Model:brine Piping Sump / Trench Sensor(s).Model:ND float Fill Sump Sensor(s).Model:ND float Mechanical Line Leak Detector.Model: Electronic Line Leak Detector.Model:Veeder Root DPLLD - Tank Overfill / High-Level Sensor.Model:HLA Other (specify equipment type and model in Section E on Page 2). Tank ID:2 - UNLEADED In-Tank Gauging Probe.Model:mag Annular Space or Vault Sensor.Model:brine Piping Sump / Trench Sensor(s).Model:ND float Fill Sump Sensor(s).Model:ND float Mechanical Line Leak Detector.Model: Electronic Line Leak Detector.Model:Veeder Root DPLLD - Tank Overfill / High-Level Sensor.Model:HLA Other (specify equipment type and model in Section E on Page 2). Tank ID:3 - PREMIUM In-Tank Gauging Probe.Model:mag Annular Space or Vault Sensor.Model:brine Piping Sump / Trench Sensor(s).Model:ND float Fill Sump Sensor(s).Model:ND float Mechanical Line Leak Detector.Model: Electronic Line Leak Detector.Model:Veeder Root DPLLD - Tank Overfill / High-Level Sensor.Model:HLA Other (specify equipment type and model in Section E on Page 2). Tank ID:4 - UltraZol 9888 In-Tank Gauging Probe.Model:mag Annular Space or Vault Sensor.Model:brine Piping Sump / Trench Sensor(s).Model:ND float Fill Sump Sensor(s).Model: Mechanical Line Leak Detector.Model: Electronic Line Leak Detector.Model:Veeder Root DPLLD Tank Overfill / High-Level Sensor.Model:HLA Other (specify equipment type and model in Section E on Page 2). Dispenser ID:1/2 Dispenser Containment Sensor(s).Model:ND float Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID:3/4 Dispenser Containment Sensor(s).Model:ND float Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID:5/6 Dispenser Containment Sensor(s).Model:ND float Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID:7/8 Dispenser Containment Sensor(s).Model:ND float Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID:9/10 Dispenser Containment Sensor(s).Model:ND float Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID:11/12 Dispenser Containment Sensor(s).Model:ND float Shear Valve(s). Dispenser Containment Float(s) and Chain(s). *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 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; (check all that apply): System set-up Alarm history report Technician Name (print):Dylan Brant Signature: Certification No.:C23623 License. No.: Testing Company Name:Tanknology Phone No.:(800) 800-4633 Testing Company Address:11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing:11/4/2019 Page 1 of 4 03/01 Monitoring System Certification MONITORING SYSTEM CERTIFICATION This form is used to document testing and servicing of tank and piping leak monitoring equipment. If required by applicable law, a copy of the completed form must be provided by the Testing Contractor or owner to the governing UST agency as required by regulation. A. General Information Facility Name:Costco #1363 Eagan Bldg. No.: Site Address:995 Blue Gentian Drive City:Eagan State:MN Zip:55121 Facility Contact Person:Contact Phone No.:- Make/Model of Monitoring System:Veeder Root TLS-450 PLUS Date of Testing/Servicing:11/4/2019 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: In-Tank Gauging Probe.Model: Annular Space or Vault Sensor.Model: Piping Sump / Trench Sensor(s).Model: Fill Sump Sensor(s).Model: Mechanical Line Leak Detector.Model: Electronic Line Leak Detector.Model: Tank Overfill / High-Level Sensor.Model: Other (specify equipment type and model in Section E on Page 2). Tank ID: In-Tank Gauging Probe.Model: Annular Space or Vault Sensor.Model: Piping Sump / Trench Sensor(s).Model: Fill Sump Sensor(s).Model: Mechanical Line Leak Detector.Model: Electronic Line Leak Detector.Model: Tank Overfill / High-Level Sensor.Model: Other (specify equipment type and model in Section E on Page 2). Tank ID: In-Tank Gauging Probe.Model: Annular Space or Vault Sensor.Model: Piping Sump / Trench Sensor(s).Model: Fill Sump Sensor(s).Model: Mechanical Line Leak Detector.Model: Electronic Line Leak Detector.Model: Tank Overfill / High-Level Sensor.Model: Other (specify equipment type and model in Section E on Page 2). Tank ID: In-Tank Gauging Probe.Model: Annular Space or Vault Sensor.Model: Piping Sump / Trench Sensor(s).Model: Fill Sump Sensor(s).Model: Mechanical Line Leak Detector.Model: Electronic Line Leak Detector.Model: Tank Overfill / High-Level Sensor.Model: Other (specify equipment type and model in Section E on Page 2). Dispenser ID:13/14 Dispenser Containment Sensor(s).Model:ND float Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID:15/16 Dispenser Containment Sensor(s).Model:ND float Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID:17/18 Dispenser Containment Sensor(s).Model:ND float Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID:19/20 Dispenser Containment Sensor(s).Model:ND float Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID:21/22 Dispenser Containment Sensor(s).Model:ND float Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID:23/24 Dispenser Containment Sensor(s).Model:ND float Shear Valve(s). Dispenser Containment Float(s) and Chain(s). *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 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; (check all that apply): System set-up Alarm history report Technician Name (print):Dylan Brant Signature: Certification No.:C23623 License. No.: Testing Company Name:Tanknology Phone No.:(800) 800-4633 Testing Company Address:11000 N. MoPac Expressway Suite 500 Date of Testing/Servicing:11/4/2019 Page 2 of 4 03/01 Monitoring System Certification D. Results of Testing/Servicing Software Version Installed: Complete the following checklist: Yes No* N/A Is the visual alarm on the console operational? Yes No* N/A Is the audible alarm on the console operational? Yes No Is the external visual overfill alarm (light unit) present? Yes No* N/A Is the external visual overfill alarm operating properly? Yes No Is the external audible overfill alarm (light unit) present? Yes No* N/A Is the external audible overfill alarm operating properly? 90 % N/A At what percent of tank(s) capacity is the external alarm programmed to trigger? If different % between tanks, clarify in section E. Yes No* N/A Were all sensors visually inspected, functionally tested, and confirmed operational? Yes No* N/A Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their proper operation? Yes No* N/A For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate positive shut-down? (Check all that apply) Sump/Trench Sensors; Dispenser Containment Sensors. Did you confirm positive shut-down due to leaks and sensor failure/disconnection? Yes; No Yes* No Was any monitoring equipment replaced? If yes, identify specific sensors, probes, or other equipment replaced and list the manufacturer name and model for all replacement parts in Section E, below. Yes* No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply) Product; Water. If yes, describe causes in Section E, below. Yes No*Was monitoring system set-up reviewed to ensure proper settings? Attach set up reports, if applicable Yes No*Is all monitoring equipment operational per manufacturer's specifications, including battery backup? Backup Battery reading, if applicable : N/A * In Section E below, describe how and when these deficiencies were or will be corrected. E. Comments: Page 3 of 4 03/01 F. In-Tank Gauging / SIR Equipment: Check this box if tank gauging is used only for inventory control. Check this box if no tank gauging or SIR equipment is installed. This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring. Complete the following checklist: Yes No*Were all tank gauging probes visually inspected for damage and residue buildup? Yes No*Was accuracy of system product level readings tested? Yes No*Was accuracy of system water level readings tested? Yes No*Were all probes reinstalled properly? Yes No*Were all items on the equipment manufacturer's maintenance checklist completed? * In the Section H, below, describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): Check this box if LLDs are not installed. Complete the following checklist: Yes No* N/A For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? (Check all that apply) Simulated leak rate: 3 g.p.h.; 0.1 g.p.h; 0.2 g.p.h. Yes No*Were all LLDs confirmed operational and accurate within regulatory requirements? Yes No*Was the testing apparatus properly calibrated? Yes No* N/A For mechanical LLDs, does the LLD restrict product flow if it detects a leak? Yes No* N/A For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? Yes No* N/A For electronic LLDs that are programmed for positive shut down, does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? Yes No* N/A For electronic LLDs that are programmed for positive shut down, does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? Yes No* N/A For electronic LLDs, have all accessible wiring connections been visually inspected? Yes No*Were all items on the equipment manufacturer's maintenance checklist completed? * In the Section H, below, describe how and when these deficiencies were or will be corrected. H.Comments: DID OVERALL MONITOR SYSTEM TESTING PASS (Check One)? YES NO INCONCLUSIVE Page 4 of 4 03/01 WO: 6365789 Page 1 of 3 Customer Name:Costco #1363 Eagan Location #:1363 Eagan City:Eagan State:MN Zip:55121 SPILL/OVERFILL CONTAINMENT BOXES Facility is Not Equipped With Fill Riser Containment Sumps Test Date: 11/4/2019 Fill Riser Containment Sumps are Present, but were Not Tested Double Wall: Bucket Diameter: Bucket Depth: Test Method Developed By: Test Method Used By: Test Equipment Used: Equipment Resolution: Wait time between applying pressure/vacuum/water and starting test Test Start Time: Initial Reading (R I ): Test End Time: Final Reading (R F ): Test Duration: Change in Reading (R F -R I ): Pass/Fail Threshold or Criteria: Test Result: Spill Box # Tank 1 UNLEADED - Fill 1 - Direct N 13.00 15.00 Industry Standard-PEI RP 1200 Hydrostatic LAKE TEST 0.0625 in. 5 min 16:45:00 13.50 in. 17:45:00 13.50 in. 1 hr 0.00 in. +/- 0.1250 Pass Spill Box # Tank 1 UNLEADED - Vapor 1 - Direct N 13.00 15.00 Industry Standard-PEI RP 1200 Hydrostatic LAKE TEST 0.0625 in. 5 min 16:45:00 14.00 in. 17:45:00 14.00 in. 1 hr 0.00 in. +/- 0.1250 Pass Spill Box # Tank 2 UNLEADED - Fill 1 - Direct N 13.00 15.00 Industry Standard-PEI RP 1200 Hydrostatic LAKE TEST 0.0625 in. 5 min 16:45:00 12.00 in. 17:45:00 12.00 in. 1 hr 0.00 in. +/- 0.1250 Pass Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) Technician Name:Dylan Brant Test Date:11/4/2019 Technician Signature:Certification #:138140 WO: 6365789 Page 2 of 3 Customer Name:Costco #1363 Eagan Location #:1363 Eagan City:Eagan State:MN Zip:55121 SPILL/OVERFILL CONTAINMENT BOXES Facility is Not Equipped With Fill Riser Containment Sumps Test Date: 11/4/2019 Fill Riser Containment Sumps are Present, but were Not Tested Double Wall: Bucket Diameter: Bucket Depth: Test Method Developed By: Test Method Used By: Test Equipment Used: Equipment Resolution: Wait time between applying pressure/vacuum/water and starting test Test Start Time: Initial Reading (R I ): Test End Time: Final Reading (R F ): Test Duration: Change in Reading (R F -R I ): Pass/Fail Threshold or Criteria: Test Result: Spill Box # Tank 2 UNLEADED - Vapor 1 - Direct N 13.00 15.00 Industry Standard-PEI RP 1200 Hydrostatic LAKE TEST 0.0625 in. 5 min 16:45:00 13.00 in. 17:45:00 13.00 in. 1 hr 0.00 in. +/- 0.1250 Pass Spill Box # Tank 3 PREMIUM - Fill 1 - Direct N 13.00 15.00 Industry Standard-PEI RP 1200 Hydrostatic LAKE TEST 0.0625 in. 5 min 16:45:00 12.50 in. 17:45:00 12.50 in. 1 hr 0.00 in. +/- 0.1250 Pass Spill Box # Tank 3 PREMIUM - Vapor 1 - Direct N 13.00 15.00 Industry Standard-PEI RP 1200 Hydrostatic LAKE TEST 0.0625 in. 5 min 16:45:00 13.00 in. 17:45:00 13.00 in. 1 hr 0.00 in. +/- 0.1250 Pass Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) Technician Name:Dylan Brant Test Date:11/4/2019 Technician Signature:Certification #:138140 WO: 6365789 Page 3 of 3 Customer Name:Costco #1363 Eagan Location #:1363 Eagan City:Eagan State:MN Zip:55121 SPILL/OVERFILL CONTAINMENT BOXES Facility is Not Equipped With Fill Riser Containment Sumps Test Date: 11/4/2019 Fill Riser Containment Sumps are Present, but were Not Tested Double Wall: Bucket Diameter: Bucket Depth: Test Method Developed By: Test Method Used By: Test Equipment Used: Equipment Resolution: Wait time between applying pressure/vacuum/water and starting test Test Start Time: Initial Reading (R I ): Test End Time: Final Reading (R F ): Test Duration: Change in Reading (R F -R I ): Pass/Fail Threshold or Criteria: Test Result: Spill Box # Tank 4 UltraZol 9888 - Fill 1 - Direct N 13.00 15.00 Industry Standard-PEI RP 1200 Hydrostatic LAKE TEST 0.0625 in. 5 min 16:45:00 14.50 in. 17:45:00 14.50 in. 1 hr 0.00 in. +/- 0.1250 Pass Spill Box # Tank 4 UltraZol 9888 - Vapor 1 - Direct N 13.00 15.00 Industry Standard-PEI RP 1200 Hydrostatic LAKE TEST 0.0625 in. 5 min 16:45:00 14.75 in. 17:45:00 14.75 in. 1 hr 0.00 in. +/- 0.1250 Pass min +/- Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) Technician Name:Dylan Brant Test Date:11/4/2019 Technician Signature:Certification #:138140 WO: 6365789 2 inch Pressure Decay Test TP201.3 Store Information Testing Company Site Name :Costco #1363 Eagan Name :TANKNOLOGY INC. Address :995 Blue Gentian Drive Eagan, MN 55121 Address :11000 N. MoPac Expressway Suite 500 Austin, TX 78759 Phone :-Phone :(800) 800-4633 Stage I System?yes Stage II System?no Total # of Nozzles :1 Products per Nozzle :1 Tanks Manifolded ?Yes Drop-Out tank present?no Total # of Tanks Tested :3 Tank Information : Product Grade : Tank Capacity, gallons : Gasoline, gallons : Ullage, gallons : Testing Information : Start Time : Initial Pressure, wcg : Pressure @ 1 minute(s) : Pressure @ 2 minutes : Pressure @ 3 minutes : Pressure @ 4 minutes : Pressure @ 5 minutes : Allowable Final Pressure : Pass/Fail (Enter "GF" Gross Failure) 1 UNLEADED 39854 33571 6283 17:27 2.00 2.02 2.04 2.04 2.02 2.00 1.93 Pass 2 UNLEADED 39854 35970 3884 17:27 2.00 2.02 2.04 2.04 2.02 2.00 1.93 Pass 3 PREMIUM 39854 33343 6511 17:27 2.00 2.02 2.04 2.04 2.02 2.00 1.93 Pass Total 119562 102884 16678 All 17:27 2.00 2.02 2.04 2.04 2.02 2.00 1.93 Pass Comments: Tester :Dylan Brant Test Date :11/4/2019 Signature :Work Order :6365789 WO: 6365789 PVVC tested ==>gas Manifolded Final Test Result (Pass / Fail) ==>Pass PVVC Manuf. ==>OPW Model Number ==>623V-2203 Is this Original or Replacement? Original If this cap is being replaced, check here: Manf Spec (CFH) Measured Leak Rate in ml/Min; Cracking (in H2O) Calc CFH (ml/min x .00212) Result (Pass /Fail) Pos Leak Rate(CFH)0.05 5 0.0106 Pass Low High Measured Pos Cracking (in H2O)2.50 6.00 3.35 Pass Neg Leak Rate (CFH)0.21 5 0.0106 Pass Low High Measured Neg Cracking (in H2O)-10.00 -6.00 -6.47 Pass PVVC tested ==> Manifolded Final Test Result (Pass / Fail) ==> PVVC Manuf. ==>Model Number ==> Is this Original or Replacement? Manf Spec (CFH) Measured Leak Rate in ml/Min; Cracking (in H2O) Calc CFH (ml/min x .00212) Result (Pass /Fail) Pos Leak Rate(CFH) Low High Measured Pos Cracking (in H2O) Neg Leak Rate (CFH) Low High Measured Neg Cracking (in H2O) PVVC tested ==> Manifolded Final Test Result (Pass / Fail) ==> PVVC Manuf. ==>Model Number ==> Is this Original or Replacement? Manf Spec (CFH) Measured Leak Rate in ml/Min; Cracking (in H2O) Calc CFH (ml/min x .00212) Result (Pass /Fail) Pos Leak Rate(CFH) Low High Measured Pos Cracking (in H2O) Neg Leak Rate (CFH) Low High Measured Neg Cracking (in H2O) PVVC tested ==> Manifolded Final Test Result (Pass / Fail) ==> PVVC Manuf. ==>Model Number ==> Is this Original or Replacement? Manf Spec (CFH) Measured Leak Rate in ml/Min; Cracking (in H2O) Calc CFH (ml/min x .00212) Result (Pass /Fail) Pos Leak Rate(CFH) Low High Measured Pos Cracking (in H2O) Neg Leak Rate (CFH) Low High Measured Neg Cracking (in H2O) PVVC tested ==> Manifolded Final Test Result (Pass / Fail) ==> PVVC Manuf. ==>Model Number ==> Is this Original or Replacement? Manf Spec (CFH) Measured Leak Rate in ml/Min; Cracking (in H2O) Calc CFH (ml/min x .00212) Result (Pass /Fail) Pos Leak Rate(CFH) Low High Measured Pos Cracking (in H2O) Neg Leak Rate (CFH) Low High Measured Neg Cracking (in H2O) PVVC tested ==> Manifolded Final Test Result (Pass / Fail) ==> PVVC Manuf. ==>Model Number ==> Is this Original or Replacement? Manf Spec (CFH) Measured Leak Rate in ml/Min; Cracking (in H2O) Calc CFH (ml/min x .00212) Result (Pass /Fail) Pos Leak Rate(CFH) Low High Measured Pos Cracking (in H2O) Neg Leak Rate (CFH) Low High Measured Neg Cracking (in H2O) 11000 N. MOPAC EXPRESSWAY, SUITE 500, AUSTIN, TX 78759 (800) 800-4633 QP-08-03-FF-02 Pressure Vacuum Vent Cap TP-201.1E Field Form Rev C 1/27/2011 Site Overall Test Results: Pass Total +ve LR: 0.0106 Total -ve LR: 0.0106 Test Date 11/4/2019 Technician Name Dylan Brant WO #6365789 Facility Name / Loc #Costco #1363 Eagan 1363 Eagan Street 995 Blue Gentian Drive City, St, Zip Eagan, MN 55121 Pressure Vacuum Vent Cap Test Form TP-201.1E Stage I Vapor System Survey Survey to determine compliance with Requirements of Title 40 Part 63 National Emission Standards for Hazardous Air Pollutants for Source Categories Survey Date 11/4/2019 Work Order 6365789 Cust Name / Location Number 1363 Eagan Street Address 995 Blue Gentian Drive City, State, ZipCode Eagan MN 55121 Product Stage I Type Drop Tubes Type Drop Tubes Cages Installed? Drop Tubes Max inches from tank Bottom Fill Adapters Type Vapor Adapters Type NESHAP Work Required? Vent Caps Type Labeled Positive Cracking Pressure Labeled Negative Cracking Pressure 1 UNLEADED Dual Point Straight w/ Flapper Yes 4.00 Swivel Swivel No gas Pressure Vacuum cap 2.5 - 6 -6 - -10 2 UNLEADED Dual Point Straight w/ Flapper Yes 2.00 Swivel Swivel No additive Rain Cap 3 PREMIUM Dual Point Straight w/ Flapper Yes 2.00 Swivel Swivel No 4 UltraZol 9888 Dual Point Straight w/ Flapper No 4.00 Swivel Swivel No Describe Work Required Surveyed by Signature Static Torque of Rotatable Phase I Adaptor TP - 201.1B Ref. No.: AQMD Id: Site Name:Costco #1363 Eagan Address:995 Blue Gentian Drive Phone: Testing Company Name:TANKNOLOGY INC. Address:11000 N. MOPAC EXPRESSWAY, SUITE 500, AUSTIN, TX 78759 Phone:(512) 451-6334 Brand Model of Rotatable Product/Vapor Adaptor Product Grade (Prod/Vapor) 360 Rotation Y/N Torque Run #1 Torque Run #2 Torque Run #3 Average Torque Pass/Fail EBW SWF 100B 1 UNLEADED P Yes 2.00 2.00 2.00 2.00 Pass EBW SWV 101B 1 UNLEADED V Yes 4.00 2.00 1.00 2.33 Pass EBW SWV 101B 2 UNLEADED P Yes 5.00 3.00 3.00 3.67 Pass EBW SWV 101B 2 UNLEADED V Yes 2.00 1.00 1.00 1.33 Pass EBW SWV 101B 3 PREMIUM P Yes 5.00 5.00 4.00 4.67 Pass EBW SWV 101B 3 PREMIUM V Yes 4.00 2.00 1.00 2.33 Pass EBW SWV-101SS 4 UltraZol 9888 P Yes 3.00 2.00 1.00 2.00 Pass EBW SWV-101SS 4 UltraZol 9888 V Yes 2.00 1.00 1.00 1.33 Pass Comments/Repairs: Tester:Dylan Brant Tester Id:138141 Signature:Test Date:11/4/2019 WO: 6365789 Overfill Prevention Equipment Inspection OPW 61 and 71 Series Overfill Prevention Device Inspection Date:11/4/2019 Customer Name:COSTCO WHOLESALE Location #:1363 Eagan Location Address:995 Blue Gentian Drive ,Eagan ,MN , 55121 OPW Model Number:71-SO PART 1) Proper height setting calculation Maximum Tank Volume per: Tank Chart A gallons Max shut off requirement for Flapper is 95% B 95% Multiply Maximum tank volume by 95% C gallons Use tank chart to determine height of calculated volume D inches Measure top of fill riser threads, or face seal adapter E inches Tank diameter From Chart F inches Upper Tube in tank (G) F - D = G G inches Subtract 2 inches from upper tube in tank G - 2"= K K inches Calculated minimum upper tube length (I) K + E = I I inches Actual measured upper tube length (Without fill adapter) (J) J inches PART 2) Device certification criteria evaluation Criteria 1 Does the overfill prevention device meet the 95% requirement? Criteria 1a If the final shutoff volume is installed greater than 95%, is there at least 250 gallons of ullage above the overfill device activation point to ensure that none of the tank top fittings are exposed to product, meeting the criteria established in EPA 280.20iic and per OPW installation guidelines. Criteria 2 Is the Actual measured upper tube length 6.5 inches or more than the fill riser? (J must be 6.5" or more than E) Criteria 3 Does the overfill prevention device function as required? (Inspect the device for damage, contamination, freedom of movement, weakening due to wear and corrosion) PART 3) Device Certification PASS / FAIL Technician certifies that the device is operationally compliant. 1 39854 0.95 37861.300 107.625 52.000 119.625 12.000 10.000 62.000 68.500 Yes NA Yes Yes Pass 2 39854 0.95 37861.300 107.625 51.000 119.625 12.000 10.000 61.000 68.000 Yes NA Yes Yes Pass 3 39854 0.95 37861.300 107.625 50.000 119.625 12.000 10.000 60.000 67.000 Yes NA Yes Yes Pass 4 1500 0.95 1425.000 42.875 42.000 47.625 4.750 2.750 44.750 67.000 Yes NA Yes Yes Pass Comments: Signature of Technician: Date: 11/4/2019 Dylan Brant WO: MW3- 6365789 Overfill Alarm Operation Inspection Location Name: Costco #1363 Eagan Date: 11/4/2019 Address: 995 Blue Gentian Drive City: Eagan State: MN ' This procedure is to determine whether the high level alarm is operational and will trigger when the tank is no more than 90% full. See PEI/RP 1200, Section 7.3 for the inspection procedure. This procedure is applicable to tank level monitor stems that touch the bottom of the tank when in place. Tank number Product Stored: Tank Level Monitor Brand 1. Tank Volume, gallons 2. Tank Diameter,inches 3. Does the overfill alarm activate the test mode at the console? 4. When activated,can the overfill alarm be heard and seen while delivering to the tank? 5. After removing the probe from the tank, has it been inspected and any damaged or missing parts replaced? 6. Float moves freely on the stem without binding? 7. Does moving product level float up the stem trigger alarm? 8. Inch level from bottom of stem when 90% alarm is triggered? 9. Tank volume at inch level in Line 8 10. Calculate (Line 9 / Line 1) x 100 11. Is line 10 equal to or less than 90%? 12. Does the fuel float level on the console agree with the guage stick reading? 13. Does the overfill alarm activate at 90% or less than the tank capacity Test Result 1 UNLEADED TLS-450 PLUS 39854 127 [x]Yes [ ]No [x]Yes [ ]No [x]Yes [ ]No [x]Yes [ ]No [x]Yes [ ]No 108.00 in. 35869.00 gal 90.00% [x]Yes [ ]No [x]Yes [ ]No [x]Yes [ ]No [x]Pass [ ]Fail 2 UNLEADED TLS-450 PLUS 39854 126 [x]Yes [ ]No [x]Yes [ ]No [x]Yes [ ]No [x]Yes [ ]No [x]Yes [ ]No 107.00 in. 35869.00 gal 90.00% [x]Yes [ ]No [x]Yes [ ]No [x]Yes [ ]No [x]Pass [ ]Fail 3 PREMIUM TLS-450 PLUS 39854 126 [x]Yes [ ]No [x]Yes [ ]No [x]Yes [ ]No [x]Yes [ ]No [x]Yes [ ]No 108.00 in. 35869.00 gal 90.00% [x]Yes [ ]No [x]Yes [ ]No [x]Yes [ ]No [x]Pass [ ]Fail 4 UltraZol 9888 TLS-450 PLUS 1500 54 [x]Yes [ ]No [x]Yes [ ]No [x]Yes [ ]No [x]Yes [ ]No [x]Yes [ ]No 48.00 in. 1362.00 gal 90.00% [x]Yes [ ]No [x]Yes [ ]No [x]Yes [ ]No [x]Pass [ ]Fail [ ]Yes [ ]No [ ]Yes [ ]No [ ]Yes [ ]No [ ]Yes [ ]No [ ]Yes [ ]No [ ]Yes [ ]No [ ]Yes [ ]No [ ]Yes [ ]No [ ]Pass [ ]Fail If any answers in Lines 3, 4, 5, 6, 7, or 11 are "No" the system has failed the test. Comments Tester's Name: Dylan Brant Signature: Revised 10/22/2014 WO: 6365789 Emergency Stop (E-Stop / ESO) Periodic Inspection Facility Information Technician Information Site #: Costco #1363 Eagan 1363 Eagan Date: 11/4/2019 Address: 995 Blue Gentian Drive Name: Dylan Brant City / State: Eagan MN Technician Signature: The objective of this test is to provide assurance that the when the E-Stop switch is activated, all the fueling system circuits (turbines, and dispensers) are de-energized, and remain de-energized until they are re-set manually). The test procedures and guidelines shall be in accordance with the E-Stop Testing Process. SITE DATA 1 Number of E-Stop switches INSIDE of the building: 1 2 Number of E-Stop switches OUTSIDE of the building: 2 PERFORMANCE DATA Yes No NA 3 You have added or confirmed that all E-Stop locations are on the Site Diagram 4 Do all E-Stops shutdown power to ALL DISPENSERS 5 Do all E-Stops shutdown power to ALL STP's 6 Are ALL E-Stops clearly Labeled 7 Are the TURBINE BREAKERS clearly identified / labeled POST TEST 8 All equipment secured and any access ports, lids, enclosures are closed. 9 All safety barricades and test equipment has been properly removed 10 E-Stop was reset and all dispensing functions are normal E-Stop Inspection Results 11 PASS FAIL INCONCLUSIVE Comments (Clearly describe any deficiencies found) WO: 6365789 Other Sump Other Sump Other Sump Other Sump Other Sump Other Sump Extinguisher & Sensor Placement Inspection Location Number: Costco #1363 Eagan Date: 11/4/2019 City: Eagan State: MN Inspection Company: Tanknology Inc., 11000 N. Mopac Expressway #500, Austin, TX 78759 Extinguisher is in place and secure? Extinguisher arrow is in the green? Comments Sensor mounting bracket functional? Sensor is placed at lowest point? Was sensor at lowest point upon arrival? Comments Tank Sumps Tank Sumps 87 A Turbine Sump Yes No Yes No Yes No Yes No Yes No 87 A Fill Sump Yes No Yes No Yes No Yes No Yes No 87 B Turbine Sump Yes No Yes No Yes No Yes No Yes No 87 B Fill Sump Yes No Yes No Yes No Yes No Yes No 91 Turbine Sump Yes No Yes No Yes No Yes No Yes No 91 Fill Sump Yes No Yes No Yes No Yes No Yes No Additive Tank Sump Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Under Dispenser Containment Sumps Under Dispenser Containment Sumps Dispenser 1/2 Yes No Yes No Yes No Yes No Yes No Dispenser 3/4 Yes No Yes No Yes No Yes No Yes No Dispenser 5/6 Yes No Yes No Yes No Yes No Yes No Dispenser 7/8 Yes No Yes No Yes No Yes No Yes No Dispenser 9/10 Yes No Yes No Yes No Yes No Yes No Dispenser 11/12 Yes No Yes No Yes No Yes No Yes No Dispenser 13/14 Yes No Yes No Yes No Yes No Yes No Dispenser 15/16 Yes No Yes No Yes No Yes No Yes No Dispenser 17/18 Yes No Yes No Yes No Yes No Yes No Dispenser 19/20 Yes No Yes No Yes No Yes No Yes No Dispenser 21/22 Yes No Yes No Yes No Yes No Yes No Dispenser 23/24 Yes No Yes No Yes No Yes No Yes No Other Miscellaneous Containment Sumps Other Miscellaneous Containment Sumps Vent Box Yes No Yes No Yes No Yes No Yes No tans sump 1 Yes No Yes No Yes No Yes No Yes No trans sump 2 Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No UST Containment Sump Inspection Form Location Name: Costco #1363 Eagan Date: 11/4/2019 Address: 995 Blue Gentian Drive City: Eagan State: MN Sump is clean and dry Sump is liquid tight with no visual failure points Comments/Follow-up action required Tank Sumps 87 A Turbine Sump Yes No Yes No 87 A Fill Sump Yes No Yes No 87 B Turbine Sump Yes No Yes No 87 B Fill Sump Yes No Yes No 91 Turbine Sump Yes No Yes No 91 Fill Sump Yes No Yes No Additive Tank Sump Yes No Yes No Other Tank Sump:Yes No Yes No Other Tank Sump:Yes No Yes No Other Tank Sumps:Yes No Yes No Under Dispenser Containment Sumps Dispenser 1/2 Yes No Yes No Dispenser 3/4 Yes No Yes No Dispenser 5/6 Yes No Yes No Dispenser 7/8 Yes No Yes No Dispenser 9/10 Yes No Yes No Dispenser 11/12 Yes No Yes No Dispenser 13/14 Yes No Yes No Dispenser 15/16 Yes No Yes No Dispenser 17/18 Yes No Yes No Dispenser 19/20 Yes No Yes No Dispenser 21/22 Yes No Yes No Dispenser 23/24 Yes No Yes No Other Miscellaneous Containment Sumps Vent Box Yes No Yes No Other Sump:Yes No Yes No Other Sump:Yes No Yes No Revised 10/22/2014 WO: 6365789 Site Diagram (This site diagram is for reference only and is not drawn to scale) Work Order:6365789 Site ID / Name:1363 Eagan / Costco #1363 Eagan Address:995 Blue Gentian Drive City:Eagan State:MN Zip:55121 W.O.# MW3-6365789 Cust Ref#: CONTRACT #17-0406-02 1 W.O.# MW3-6365789 Cust Ref#: CONTRACT #17-0406-02 2 W.O.# MW3-6365789 Cust Ref#: CONTRACT #17-0406-02 1 W.O.# MW3-6365789 Cust Ref#: CONTRACT #17-0406-02 2 W.O.# MW3-6365789 Cust Ref#: CONTRACT #17-0406-02 3 W.O.# MW3-6365789 Cust Ref#: CONTRACT #17-0406-02 4 W.O.# MW3-6365789 Cust Ref#: CONTRACT #17-0406-02 5 W.O.# MW3-6365789 Cust Ref#: CONTRACT #17-0406-02 6