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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 />10146285 <br />08/30/22 <br />Facility Name <br />Costco #658 Tracy <br />Facility Address <br />3250 West Grant Line Rd. <br />City <br />Tracy <br />ZIP Code <br />95377 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />Alltech Petro, Inc. <br />Phone <br />209-559-1616 <br />Mailing Address <br />P.O. Box 4208 Sonora, Ca 95370 <br />Service Technician Performing Test <br />Isaac Anderson <br />Contractor/Tank Tester License Number <br />CA 623541/09-1749 <br />ICC Number <br />8146912 <br />ICC Expiration Date <br />09/10/22 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder-TEC ATG Tech #1336878 <br />08/29/24 <br />Vaporless LDT-890 LDT #2113 <br />04/18/23 <br />OPW #100456 <br />06/02/24 <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 />Date <br />08/30/22 <br />Total # of Pages <br />6 <br />l/ <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 />