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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 /> LISTs 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 / 19 <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 /> Isaac Anderson <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Ca 623541 /09 - 1 749 8146912 2/23/2020 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder- Root Level IV #836878 06/ 12/20 <br /> Va orless LDT-890 LDT #2113 04/07/21 a <br /> OPW # 100456 04/ 19/20 <br /> Phil -Tite # 1022863709 05/ 15/20 <br /> 111 . RESULTS OF TESTING/SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> ® Monitoring System Set-up ® Alarm History Report <br /> Was any monitoring equipment replaced ? El M ❑ <br /> (If "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) <br /> Was damage , debris , or liquid found inside any secondary containment systems? El ® I] <br /> (If "Yes, " describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? ® F1 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 /> Y10 <br /> i A \/ <br /> i <br /> Al 11H <br /> t <br /> �.T <br /> k <br /> i <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 . , manufacture s' checklists , monitoring system set-up , alarm history report, etc . ) necessary <br /> to verify that this information and 94ving the la out of UST system is complete and accurate . <br /> UST Service Technician Signature <br /> i <br /> in = Irientifirnfinn_ VPH = Var111Im/PrPCCiirP.MVrfrrtctafir. I inr o I Inrlar kruancar rnntainmant <br />