Laserfiche WebLink
Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation P Repair ❑ 12 Month <br /> 1. FACILITY INFORMATION <br /> cERs ID Certification 10146299 06/25/2024Date <br /> Facility Name Costco 658 Tracy <br /> Facility AddressCity 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 Joslyn <br /> Contractor/Tank Tester License Number <br /> 804431 <br /> ICC Number 10194856 ICC Expiration Date <br /> 4/16/2026 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root 09/07/2024 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> l 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 /> �n 06/25/2024 8 <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 />