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Jul . 2 . 2019 3 . 05PM Donlee Pump Co No , 2195 P . 2 i <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 0) <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 forin to the local agency regulating the <br /> USTs within 30 days of the date or the monitoring system certilicaflon . <br /> I . FACILITY INFORMATION <br /> GERS ID Pate of onitori 8 stem Certification <br /> 26 11 1 <br /> Business Name (Same as Facility Name or DBA — Doing BusinessAs.j BU di # <br /> ER VINE <br /> Business Site Address Ciry ZIP Code <br /> 4733 South Hwy 99 Frontage Road Stockton 195340 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing Me Certification Phone # <br /> Donlee Pump Company ( 209 ) 537 - 5396 Ext . <br /> Mailing Address <br /> 2825 Railroad Ave . Ceres , CA , 96307 <br /> Name Of UST Service Technician Performing the Certification (Print a$ Shown on the Icc certification.) <br /> Mario Romero <br /> Conimctorfrank Tester License # 78T034353 <br /> wllon # ICC Cedilication Expiration Dale <br /> • 9 0-2Q19 <br /> Monitoring5 Stern I rainingand Cer6ficallons Ust all applicable certilicaflons. E Iratlon Date <br /> Incon 1027353709 2019 <br /> Veeder Root 838135 20217 <br /> 11I. RESULTS OF TESTING/SERVICING <br /> Indfcate and attach the following reports if the monitoring equipment is capable of generating alther. FY N NA <br /> N Monitoring System 3el-up ® Alarm History Report <br /> Was any monitoring equipmenC replaced? N ❑ <br /> (If 'Yes, " identify the spectge devices replaced and list the manufacturer and model for all replacement parts fn 59cllan IV below.) <br /> Was damage, debris , or liquid found Inside any secondary containment Systems? ❑ <br /> (if 'Yas, ' doscrlbe what was found in sacllon 11( below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? TED] <br /> 117 ❑ <br /> (If "No, " describe why In section IV below.) <br /> IV? COMMENTS <br /> fi uirecled to uss this section, describe how and when the Issues were or will be correcteor <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment Identified in this document was inspectedfservieed In accordance with California Code of <br /> Regulations , title 23, division 3 , chapter 16, section 2635 and all Information contained herein Is true and accurate. Attached to <br /> this certification Is information (e.g. , manufac(urers' checklists, monitoring system set-up, alarm history report, etc, ) necessary <br /> to verify that this information and the site plan showing the layout of U5T s stem is cam tete and accurate. <br /> UST Seryhntci <br /> l Tegan Si u <br /> i <br /> i <br /> i <br /> ,....,-,.. .. „, . , . MOP i.._ ._... _ ._ , _, n _ _ _ y- .. 0 . ...a.... In � b7...,,uG....ti...+ b'f• - M�r,ranllnnol f'n/1n f'ru ,»nil V = Vec N = Nn NA G NAF atlriitM,,t1tA <br />