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Appendix A <br /> Underground Storage Tank <br /> Monitoring System Certification Forma <br /> TYPE OF ACTION ❑ Installation ❑ Repair M 12 Month <br /> 1�:FAC�ILITY��INFORMATION <br /> CERS ID Certification Date <br /> 8/16/2021 <br /> Facility Name <br /> State Wide Petroleum <br /> Facility Address City ZIP Code <br /> 1700 E. Yosemite Ave. Manteca 94566 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Donlee Pump Company (209) 537-9396 <br /> Mailing Address <br /> 2825 Railroad Ave. Ceres, CA. 95307 <br /> Service Technician Performing Test <br /> Jerry Langrell <br /> Contractor/Tank Tester License Number <br /> ICC Number ICC Expiration Date <br /> 8899490 7/23/2022 <br /> 3 `TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Incon 10/18/2022 <br /> Veeder Root 11/20/2021 <br /> Vaporless 8/13/2021 <br /> 4, CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 hereby certify that the monitoring system is operational in accordance with California Code <br /> of Regulations, title 23, division 3, chapter 16, section 2638; that required supporting <br /> documentation is attached; and all information contained herein is accurate, <br /> Service Tech ' is ature Date Total # of Pages <br /> 8/6r'�( 1� <br /> f <br /> i <br /> CERS = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br /> ICC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable, SW @ Single- <br /> Walled, UDC = Under-Dispenser Containment, UST = Underground Storage Tank, <br /> VPH = Vacuum/Pressure/Hydrostatic <br /> Page 1 of 6 <br />