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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 ID 10146285 Certification Date <br /> 6/20/25 <br /> Facility Name Costco 658 Tracy <br /> Facility Address City T ZIP Code <br /> 3250 W GRANTLINE RD. racy 95377 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> JONES COVEY GROUP (877)972-7581 <br /> Mailing Address9595 LUCAS RANCH RD. #100 RANCHO CUCAMONGA, CA. 91730 <br /> Service Technician Performing Test <br /> Steve Johnson <br /> Contractor/Tank Tester License Number <br /> 804431 <br /> ICC Number 8143759 ICC Expiration Date <br /> 1/26/26 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> VEEDER ROOT-B41803 5/14/26 <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 /> .5&'Ve 01 6/20/25 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 />