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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ® 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10146151 05/16/23 <br /> Facility Name <br /> Costco #1091 Lodi <br /> Facility Address City ZIP Code <br /> 2680 Reynolds Ranch Parkway Lodi 95240 <br /> 11-SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Alltech Petro, Inc. 209-559-1616 <br /> Mailing Address <br /> P.O. Box 4208 Sonora, Ca 95370 <br /> Service Technician Performing Test <br /> Isaac Anderson <br /> Contractor/Tank Tester License Number <br /> CA 623541/09-1749 <br /> ICC Number ICC Expiration Date <br /> 8146912 09/10/24 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder-Root ATG Tech #1336878 08/29/24 <br /> Vaporless LDT-890 LDT #2113 04/18/25 <br /> OPW #100456 06/02/24 <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 /> 05/16/23 6 <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 />