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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) <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 clays of the date of the monitoring system certification . <br /> I . FACILITY INFORMATION <br /> CER S ID Date of Monitoring System Certification <br /> a � <br /> Business Name (Same as Facility Name or DBA — Doing Business As.) Building # <br /> Statewide Petroleum <br /> Business Site Address City ZIP Cade <br /> 1700_ E . Yosemite Ave . Manteca . 94566 <br /> II . 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 Technician Performing the Certification (Arfat as shown on the ICC Cerifficatlon.) <br /> Anthony L.eivas <br /> �j <br /> Contractorfl'ank Tester License # ICC Certification # lCC Certliication Expiration Date <br /> 8220961 217119 <br /> Monitoring System Tra ning and Certifcations List all a licable certifications. Expiration Date <br /> CCS C •r � t� cue_ g <br /> Ill . RESULTS OF TESTINGiSERVJCING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> Is Monitoring System Set-up ❑ Alarm History Report <br /> Was any monitoring equipment replaced? [S( ❑ ❑ <br /> (if "Yps, " Identify the specific devices replaced and list the manufacturer and model for all replacement parts in section II/ below.) _ <br /> Was damage , debris , or liquid found Inside any secondary containment systems? El <br /> (if "Yos, " describe what was found In section IV below.) El <br /> Is all monitoring equipment operational per manufacture's specifications? ❑ ❑ <br /> (if Wo, " describe why hr 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 /> IV Boa <br /> Oi9 <br /> ENVIRONMENTAL <br /> V. 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 Code of <br /> Regulations , title 23, division 3 , chapter 18, section 2% 38 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 . ved , that this information tl the site plan showing the layout of UST s stem is complete and accurate. <br /> US'r Stvice Technician Signet ur _ <br /> GERS = California Environmental Reporting System, ID = identification, ICC = IntemaUonal Code Council, Y = Yes, N =, No, NA = Not applicable <br />