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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM ( Page -I of 6 ) <br /> This form must be used to document testing and servicing of underground storage tank ( UST) monitoring equipment. A copy of this form <br /> must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local agency regulating the <br /> USTs within 30 days of the date of the monitoring system certification . <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10146285 19/26/19 <br /> Business Name (Same as Facility Name or DBA — Doing Business As.) Building # <br /> Costco #658 Tracy <br /> Business Site Address City ZIP Code <br /> 3250 West Grant Line Rd Tracy 95377 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Alltech Petro Inc . (209 ) 532 - 7320 Ext . <br /> Mailing Address <br /> P . O . Box 4208 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification .) <br /> Chad White <br /> ContractoriTank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Ca623541 /09 - 1747 8152115 2 /23/2020 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder- Root ATG Technician # 836877 6/ 11 /2021 <br /> Va orless LDT- 890 LDT #2126 5/27/2021 <br /> III . RESULTS OF TESTING/SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> M Monitoring System Set-up ® Alarm History Report <br /> Was any monitoring equipment replaced ? ❑ M El <br /> (If "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) <br /> Was damage , debris , or liquid found inside any secondary containment systems? El ® El <br /> (If "Yes, " describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? ® I] 1:1 <br /> (If "No, " describe why in section IV below.) <br /> IV. COMMENTS <br /> If directed to use this section, describe how and when the issues were or will be corrected. <br /> Jumpers are installed in UDC 's with an open end to satisfy functionality and ease of use during 989 <br /> testing . A number of the jumper hoses did not maintain a downward slope from the product pipe to <br /> the bottom of the UDC . All lines were checked in the UDC 's and routed to all maintain a downward <br /> slope from the line to the bottom of the UDC . Corrected onsite . <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment identified in this document was inspected /serviced in accordance with California Code of <br /> Regulations , title 23 , division 3 , chapter 16 , section 2638 and all information contained herein is true and accurate . Attached to <br /> this certification is information (e .g . , manufacturers ' checklists , monitoring system set-up , alarm history report, etc .) necessary <br /> to verify that this information and the site plan showing the layout of UST system is complete and accurate . <br /> UST Service Technician Signature <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = Intemational Code Council, Y = Yes, N = No, NA = Not applicable <br />