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Sep, 8. 2017 8:44AM Oonlee Pump Co No. 8205 P, 2 MONADRING SYSTEM CERTimerION For Use By All Jurisdictions Within the State of California �x Authority Cited•-Chapter 6.1, Health and Safety Code,Chapter 16,Division 3, Title 23, gtrtgri � This form must be used to document testing and servicing of monitoring equipment. " A seuatatt certification or report must be arcuated for tach monitoring sysitm control vanel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of t tai agency regulating LIST systems within 30 days of test date. dais page.. A. General Information ENVIRONNIIENTAL HEALTH ' PARTMMi ,INT i"aciiity Name: Statewide Petroleum Bldg.Na: Site Address: 9700 E.Yosemite Ave, City: Manteca Zip: I{acility Contact Person: Sunny Contact Phone No.: (408) 230-8999 Make/Model of Monitoring System: Veeder Root bate of Testing/Servicing: 8/3012017 B. Invelntory of Equipment Tested/Certified Cheek the appropriate boxes to indieste specific equipment ins eeted/serviceda Tants ID: 0- Tank ID: :9 In-Tank Ganging Probe. Model: K?t®G. 15 In-Tank flanging Probe. Model: WW �KUA IQ cannular Space or Vault Sensor. Model: �/tr+, t.12 p alar Space or Vault Sensor. Model: W JA Piping Sump/Trench Sensor(s). Model: 4 QL 7.0% KPipiag Sump/Trench Sensor(s). Madel: edL016 ^ ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Modch fil Mechanical Line Leak Detector. Model: dfAl Lam, Mechanical Line Leak Detector. Model: J, ❑Electronic Line Leak Detector. Model: ❑Electronie Line Leak Detector.. Model: Tank.Overfill/High-Level Sensor. Model: + , Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section tn Page 2). ❑Other(specific equipment type and model in Section E Page 2). Tank ID: Tank TCI: C]In-Taal:Gauging Probe. Model, ❑In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ❑Piping Sump 1 Trench Seosor(s). Model, ❑Piping Sump t Trench Sensor(s). Model: ❑Fitt Sump Sensor(s). Model• ❑fill Sump Sensorft Model: ❑'Nfeehanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector_ Model: ❑Electronic Line Leak Detector. Model: ❑Elcamic Line Leak Detector. Model: ❑Tank Overfill/high-Level Sensor. Model: ❑Tank Overfill/Nigh—Level Sensor. Model: ❑Other(speoify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Fagg 2). ]Dispenser ID: A 'Dispenser W- ?t/N -- E(Dispenscr Containment Sensor(s). Model: y('R U2k _ ❑Dispenser Containment Sensor($), Model: vi Q9 ,g Sheat Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Floats)and Chain(s). ❑1Dispenscr Containment Float(s)and Chain(s). Dispenser ID: 6P Dispenser ID: / ,R Dispenser Containment Sensor(s). Model: Jf- lAt &ffDispenser Containment Sensor(s). Model: dei; 7A$ Shear Valve(s). gShear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). L❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: )Dispenser 1"D: ❑Dispenser Containment Sensor(s). Model: _ ❑Dispenser Containment 5cnsor(s). Model: _ ❑Shear Valve(s). ❑Shear Valvc(s). ❑Dispenser Containment F toot($)and Chain(s). ❑Dispenser Containment Float(g)and Chain(s). $If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C, Certif UtiOn-I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guideline's. Attached to this Certification Is Information (e.g. manufacturers' checklists) necessary to verify that this Information is correct and a Sko-Plot)Plan showing the layout of monitoring equipment. For any 9 meat capable of generating such reports,I have I also attached a copy of the report;(check all that apply): System set-up Istoty report w—• Technician dame(print): AnthonyUlVas Signature: Certification No.: B43182 License.Ni 8220961 I Testing Company Name: Don lee Pump Company phone No.:(209) $37-9396 Testing Company Address: 2826 Railroad Ave Ceres,CA.98307 Date of Testing/servicing. 8/30/2017 US-0-36—1/6 www.unidoes.org Rev.01/17/08