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Jan . 23 , 2019 7 : 47AM Donlee Pump Co No . 1366 P . 2 UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM (page 1 of sl This form must be used to document tasting and servicing of underground storage tank (UST) monitoring equipment. A copy of this form must be provided to the UST owner or operator. The owner or operator must submit a copy of this foml to the local agency regulating the IJSI's within 30 days of the data of the monitoring system certiffeation . I. FACILITY INFORMATION CERS 117 Date of Monitoring System Certification Business Name (Sarno as FacitrYy Name orDBA - Doing Business As,) Building # Statewide Petroleum Business Site Address Clly ZIP Code 1790 E. Yosemite Ave . Manteca , 94566 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phane # Donlee Pump Company (209) 537 - 9396 Ext . Mailing Address Y 2825 Railroad Ave . Ceres , CA, 95307 Nance of UST Service Technician Performing the Certification (Print as shown on the ICC Certificallon) Anthony Lelvas Contractorfrank Teslac License # IGC Certification # ICC Certification Explfation Date 8220961 217119 Monitoring 5 stem Trainin and Certifications List all s /108610 csrtiticatiorts, Ex Icarian Date IA5 IiI, RESULTS OF TESTINGISERViCiNG Indicate andattach the following reports lythe MOrrltoring equipment is capable otgenerating either~ Y N NA N(Monitoring System Sel•up ❑ Alarm History Report Was any monitoring equipment replaced ? ❑ ❑ (it `Y,ps, " identify the speck devices replaced and list the manufsolater and model for all replacement partS 61 section IV below) Was damage, debris, or liquid found inside any secondary containment systems? ❑ ❑ (if "Yes, " describe what was found In section Wbelow.) Is all monitoring equipment operational per manufacturers specifications ? ❑ a (If "No, " doscribe why In seotion iV below) Iv. COMMENTS It directed to use tills section, describe how and when the Issues were or will be corrected, C o f e r r eA er✓ Ea ,6) r 1 -7 v. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the equipment identified in this document was inspectediserviced in accordance with California Code of Regulations, title 23, division 3 , chapter 16, section 2636 and all information contained herein is true and accurate. Attached to this certification Is information (e.g., manufacturers' checklists, monitoring system sek•up, alarm history report, etc •) necessary to .VQri that this information the site plan showin the la out of UST s stem Is corn lets and accurate , tJST S 'ce Teahniclan Signatupov floe — r ,rrfnmto GnrirAW4lenMl RPmMi m svRtam. In = kientificallom ICC = International code Councll, Y = Yes, N = No, NA w Not applicable