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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation 5a Repair ❑ 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS IDCertification Date <br /> 10146285 11-9-2022 <br /> Facility Name Costco 658 Tracy <br /> Facility Address City ZIP Code <br /> 3250 W grantline rd. Tracy 95304 <br /> [2, SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Jones Covey Group, Inc. 909-972-7581 <br /> Mailing Address 9595 Lucas Ranch Rd. Rancho Cucamonga, CA 91730 <br /> Service Technician Performing Test <br /> Justin Brewster <br /> Contractor/Tank Tester License Number <br /> 80441 A,B, HAZ <br /> ICC Number 10261691 ICC Expiration Date <br /> 11-3-2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> C27389 8/17/2023 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that the monitoring system is operational in accordance with California Code <br /> of Regulations, title 23, division 3, chapter 16, section 2638; that required supporting <br /> documentation is attached; and all information contained herein is accurate. <br /> Service Technician Signature Date Total # of Pages <br /> Digitally signed by Justin Brewster 11-9-2022 <br /> Justin Brewster <br /> Date:2022.11.09 19:25:51-08'00' <br /> CERS = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br /> ICC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable, SW = Single- <br /> Walled, UDC = Under-Dispenser Containment, UST = Underground Storage Tank, <br /> VPH = Vacuum/Pressure/Hydrostatic <br /> Page 1 of 6 <br />