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RECEIVED <br /> UNDERGROUND STORAGE TANK JI-11 i 6 Lino <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) <br /> This form must be used to document testing and servicing of underground storage tank(UST)monitori uippment. 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�i I�� ymWatirlg ��Z <br /> USTs within 30 days of the date of the monitoring system certification. t/-1LL ff II <br /> I. FACILITY INFORMATION ' <br /> E Nn <br /> CERS ID Date of Monitoring System Certification <br /> 10146143 5/7/20 <br /> Business Name(Same as Facility Name or DBA—Doing Business As.) Building# <br /> Costco #1031 Manteca <br /> Business Site Address City ZIP Code <br /> 2440 Daniel St. Manteca 95337 <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 623541/09-1749 8146912 06/12/20 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder-Root Level IV #B36878 10/22/20 <br /> Va orless LDT-890 LDT#2113 04/08/21 <br /> OPW#100456 05/16/20 <br /> Phil-Tite #1022863709 04/19/20 <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 ®Alarm History Report Y N NA <br /> Was any monitoring equipment replaced? El ® El <br /> (If"Yes,"identify the specific devices replaced and list the manufacturer and model for all replacement parts in section W below.) <br /> Was damage,debris,or liquid found inside any secondary containment systems? El ® E] <br /> (If"Yes,"describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? M 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 /> This is the lower console with the Tanks, PLLD's and Smart Sensors only. <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 an <br /> ��- ��Ihowing the layout of UST system is complete and accurate. <br /> UST Service Technician Signature <br /> CERS=California Environmental Reporting System,ID=Identification,ICC=International Code Council,Y=Yes,N=No,NA=Not applicable <br />