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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Pagel of 6) <br /> This form must be used to document testing and servicing of underground storage tank(UST)monitoring equipment. A copy of this form <br /> must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local agency regulating the <br /> USTs within 30 days of the date of the monitoring system certification. <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10146151 05/21/20 <br /> Business Name(Same as Facility Name or DBA—Doing Business As.) Building# <br /> Costco#1091 Lodi <br /> Business Site Address City ZIP Code <br /> 2680 Reynolds Ranch Parkway Lodi 95240 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> Alltech Petro Inc. (209) 532-7320 Ext. <br /> Mailing Address <br /> P.O. Box 4208 <br /> Name of UST Service Technician Performing the Certification(Print as shown on the ICC Certification.) <br /> Chad White <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> Ca 623541/09-1747 8152115 2/13/2022 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder-Root ATG Tech #B36877 06/11/21 <br /> Va oriess LDT-890 LDT#2126 05/28/20 <br /> OPW#100301 06/19/20 <br /> Phil-Tite#1015593710 05/30/22 <br /> III. RESULTS OF TESTING/SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br /> ®Monitoring System Set-up M Alarm History Report Y N NA <br /> Was any monitoring equipment replaced? E-1 ® El <br /> (If"Yes,"identify the specific devices replaced and list the manufacturer and model for all replacement pants in section IV below.) <br /> Was damage,debris,or liquid found inside any secondary containment systems? El ® El <br /> (If"Yes,"describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? ® El El <br /> (if"No,"describe why in section IV below.) <br /> IV. COMMENTS <br /> If directed to use this section,describe how and when the issues were or will be corrected. <br /> JUN 2 4 2020 <br /> ENVIR <br /> DEPARTMENT <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of <br /> Regulations,title 23,division 3,chapter 16,section 2638 and all information contained herein is true and accurate. Attached to <br /> this certification is information(e.g., manufacturers'checklists, monitoring system set-up, alarm history report,etc.)necessary <br /> to verify that this information and the site plan showing the layout of UST system is complete and accurate. <br /> UST Service Technician Signature <br /> ID=Identification,VPH=Vacuum/Pressure/Hydrostatic,UDC=Under-dispenser containment <br />