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Aug. 1$. 2016 10: 19AM Donlee Pump Co No, 5143 P. 2 MONARING SYSTEM CERTIFIAION For Use By All Jurisdictions Within the State of Cali ornia Authority Cited-Chapter 6 7,Health and Safety Code, Chapter 16,1 re 23,California Code of Regulations This form must be used to document testing and servicing of monitoring equipment,y;a�A s e,certiftcation or rcpon must be preoored for each monitoring system control caret by Ifinara the technician who performs the work. A copy of this form must be provided to the tank system ovaner/operator. The owner/operator[rust submit a copy ofltis fa a loctpenvy I regulating UST systems within 30 days of test date. ``""�'"Fab''""""" AUG 18 n4vo,, A. General Information Facility Name- Statewide Petroleum Bldg,Noy Site Address: 1700 E.Yosemite Ave. City,; Manteca — Zip; Facility Contact Person: Sunny - Contact Phone No.: (408) 230-8999 Make/Model of Monitoring System: Veeder Root Date of TesdngtServicing; SM612016 R Inventory of Equipment Tested/Cerfifled Check the APPLO riate boxes to Indicate 9jecific cam!Emeht ibspected/service Tanklll); ?-7%dn,0 TankID: C/1 ❑In-Tank Gauging probe.y Model: []In Tank Gauging Probe. Model. ❑ ter Space or Vault Senior. Model; 11 0 lar Space or Vault Sens". Model; Piping Sump/Trench Scmoi(s). Model-, Viplil-8 Sump I Trench Sensor(s). Modcl. ❑Fin Sump Sensor(s). Model; D fill Sump Seasor(s). Model; ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model; ❑Electronic Line Leak Detector. Model; ❑Electronic Line Leak Detector. Model; 171 Tank Overfill/High-Level Sensor. Model; ❑Tank Overfill/High-Level Sensor. Model; E)Other tapecify equipment type and model in Section E on Page 2). ❑other(specify equipment type and model in Section E on Page 2)- Tank r M -7 14 ri V ja tL Tank - i,- , d 11(Ala 0 1104,1, liuSing Probe. Model-, In-Tank Gauging Probe. Model: %Annular Space or Vault Sensor. Model: (I Annular Space or Vault Sensor. Model: 2 ❑Piping Sump/Trench Sensor(s). Model-. N Piping Sump/Trench Seasor(a). Model: ❑Fill Sump Sensor(s). Model: 0 PHI Sump sciison(s), Model: 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Lino Leak Detector. Model: []Tank Overfill I/High-Level Sensor. Model: 0 Tank Overfill/high-Level Sensor. Model- 0 Other(specify equipment type and model in Section E on Page 2), Other(specify equipment type and model in Section E on Page 2). Dispenser ID- Dispenser ID: �Dispenser Containment Sensors} Model, �[O VDispenser Containment Sensor(s). Model: Shear Valve(s), []Shear Valve(s). n Dispenser Containment Float(&)and Chain(s). 0 Dispenser Containment Float(g)and Chain(s). f-f 7- 91, Dispenser ID: 5 Dispenser ED: Dispenser Containment Sensor(s). Model; YDispenser Containment Sensor(s). Model; 0 I'D Shear S Dispenser Dispenser Dispenser Dispenser n ear n Dispenser p P c use n e V r K r Valve(s), is I r r ID: rD v DC C C Containment Containment Valve(s). 0 Shear Valve(s). [3 Dispenser Containment floats)and Choln(s). [3 Dispenser Containment Floal(s)and Cham(s). Dispenser Dispenser M: Dispenser 10: 0 0 Dispenser Containment Scoso4s), Model: 0 Dispenser Containment Scnsoqs) Model: Shear Valve(s), [3 Shear Valve(s). Shear is er Con 0 Dispenser Containment Float(s)and Chain(sl DDispenser Containment Floats]and Chaiit(s)� *If the facility contains more_tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certification-I certify that the equipment Identified in this document was Inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a gk-e�-Plot Plan showing the layout of monitoring N-Twinent. For any equip .t capable of generating such reports,I Itaye also attached R copy of the report;(check all that apply)[ system set-up rAlq m history re T�ohaieian Name(print): Miguel_Flores Signature: Certification No.: 8049086 License.No 157 02 I Testing Company Name: Donles Pump Company Phone No-:(209) 537-9396 Testing Company Address: 2825 Railroad Ave Cores,CA.96307 Date of Testing/Servicing: 811612016 UN-036-1/6 www.unidoes.org '.Rev.0/17108