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Aug , 30 . 2019 MOM bonlee Pump Co No , 2568 P . 2 <br /> UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of B <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 form to the local agency regulating the <br /> USTs within 30 days of the date of the monitoring system certification. <br /> I , FACILITY INFORMATION <br /> CERS ID Dale of Monitoring System Certification <br /> $/29/19 <br /> Business Name (Same as Facility Name or DBA — Doing Business As) Building # <br /> Statewide Petroleum <br /> Business Site Address City 'ZIP Code <br /> 1700 E . Yosemite Ave. , . Manteca 94566 <br /> lie UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION ' <br /> Name of Company Performing the Certification Phone # <br /> Donlee Pump Company (209) 537 - 9396 Ext , <br /> Mailing Address <br /> 2825 Railroad Ave , Ceres, CA . 95307 <br /> Name of UST Service Techoldan Performing the Certification (Print as shown on the iCC Corli ioation) <br /> Mario Romero <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 8034353 10-2020 <br /> Monitoring System Training and Certifications List all a lloeble certifications. Expiration Date <br /> Incon 1027353709 2019 <br /> Veeder Root 838135 2020 <br /> ill. d RESULTS OF TESTINGISERVICING <br /> indicate and atfachpa following reports if the monitoring equipment is capable ofgen rating either Y IN NA <br /> Monitoring system Set-up OAfarm History Deport <br /> Was any monitoring equipment replaced? 1 Q <br /> (if °Yes, " Identify the Specific devices replaced and list the manufacturer and model for all replacement parts In section IV below.) <br /> Was damage, debris, or liquid found inside any secondary containment systems? D 171 <br /> (if "Yes, " describe wi)at was found in section 1V below.) <br /> Is all monitoring equipment operational per manufacturers specifications? <br /> (If "No, " describe why in section W below.) . <br /> Iv. COMMENTS <br /> If directed to use this section, describe how and when the Issues were or will be corrected. <br /> Ve CERTIFICATION • BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Codo of <br /> Regulations, title 23, division 3 , chapter 16, section 2638 and all Information contained herein Is true and accurate. Attached to <br /> this certification is information (e. g, , manufacturers' checklists, monitoring system set-up, alarm history report, etc.) necessary <br /> to verify that, this Information and the site plan showingthe la ouf of UST s stem is coo tete anti accurate. <br /> UST Service Technician Si re <br />