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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION ❑ Installation 52 Repair ❑ 12 Month <br />1. FACILITY INFORMATION <br />CERS IDCertification <br />10146143 <br />Date <br />12-17-2024 <br />Facility Name Costco 1031 Manteca <br />Facility Address <br />2440 Daniels Street <br />City Manteca <br />ZIP Code <br />95337 <br />[Z. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />Jones Covey Group <br />Phone <br />(877)972-7581 <br />Mailing Address 9595 Lucas Ranch RD #100 <br />Service Technician Performing Test <br />Mark Bump <br />Contractor/Tank Tester License Number <br />804431 <br />ICC Number 10375356 <br />ICC Expiration Date <br />3-29-2026 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />C36282 <br />4-11-2025 <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 <br />Mark Bump <br />Date <br />12-17-2024 <br />Total # of Pages <br />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 />