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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 />10146143 5/13/21 <br />Facility Name <br />Costco #1031 Manteca <br />Facility Address City ZIP Code <br />2440 Daniels St. Manteca 95337 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />Alltech Petro Inc. <br />Phone <br />209-532-7320 <br />Mailing Address <br />P.O. Box 4208 Sonora, Ca 95370 <br />Service Technician Performing Test <br />Chad White <br />Contractor/Tank Tester License Number <br />Ca 623541/09-1747 <br />ICC Number <br />8152115 <br />ICC Expiration Date <br />2/13/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder-Root ATG Tech #1336877 <br />6/11/2021 <br />Vaporless LDT-890 #2126 <br />5/27/2021 <br />OPW #100301 <br />5/20/2022 <br />FFS EVR Phase 1 Systems #1015593710 <br />5/30/2022 <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 ® r, <br />Date <br />5/13/21 <br />Total # of Pages <br />5 <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 />