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Mar. 28. 2014 2:49PM I Donlee Pump Co. No, 6948 P. 2 M040RYNG SYSTEM CERTIFATION For Use Ey All Jurisdictions Within the State of California .Authority Cited.- Chapter 6.7, Health and Safety Code; Chapter 16., Division 3, Title 23, California Code ofRegulations r his form gust be used to document testing and servicing of monitorittg equipment Rcl4ys K eertificat2on or repo��y�t be prepared for each mcmitcrrin¢ system control pant] by the tech*"PxXUF- A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this forau to the locala ency g«nl reating UST systems within 30 days of test date. T tPaG+ @ns are w-inted bad F.+_o :; � c ^, 2 8 2 � 1 4 1 A. General Information ENVIRONMENTAL HEALTH DEPARTMENT Facility Name: Villago West Marina Bldg. No.: Site Address: 6649 Embarcadero City: Stockton Zip: 95219 Facility Contact Person: Chrls Contact phone No.: 209 951-1551 Make/Model of Monitoring System: TLS�350 Date of Testing/Servicing: 3/1312014 B. Inventory of Equipment 'Vested/Certified Check the sonroariate bnxes to indie_gte cneatilr --t Tank ID: ?'�ara Tank ID: L15 -Tank Gauging Probe_ Modol; �juiular Space or Vault Sensor. Modcl: Piping Sump / Trench Sensor(s). Model. Cl Fill Sump Scnsor(s), Modcl; Mechanical Line Leak Detector_ Model: ❑ Electronic Line Leak Detector. Model: W Tank Overfill / High -Level Sensor. Model; fjeo r.. �MeriL [ ❑ Other (specify equipment type and model in Section E on Page 2) Tank ID: b1�u1 Tank ID: [Ain Tank Chmging Probe- Model: [rAmn lar Space or Vault Sensor. Modcl; ert [27Iriping Sump I Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: Mechanical Lane Leak Detector. Model; VM l ❑ Electronic Line Leak Detector. Model; $Tank Overfill / High -Level Sensor. Model; ❑ Othcr (specify equipment type and modal in Section E on Page 2) Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: � ❑ In -Tank Gauging Probe_ Model: Annular Space or Vault Sensor. Model; ❑ Annular Space or Vault Sensor. Model; i Piping Sump / Trench Senser(s). Model: ❑ Piping Sump / Trench Sewor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s), Model: 1_l Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model; ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector, Model; ❑ Tank Overfill / High -Level Scnsor. Model: _ ❑ Tank Overfill / Higb-Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Pagc 2). Ej Other (specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: E�Pispenser Containment Scnaor(s). Model: _ ` _ ❑ Dispenser Containment Scnsor(s). Model: Z Shear Valve(s). ❑ Shear Valve(s)_ ❑ Dispenser Coritainmcnt Floats) and Chain(s), d D.ispcuscr Containment Float(s) and Chain(s). nser ID: Di;S1h_UUr Dispenser ID: pensor Cootainmcnt Sensor(s). Model: ❑ Dispenser Containment Scnsor(s). Model: _ LJ Valve(s). ❑ Shear Valvc(s). ❑ Dispenser Containment Float(s) and Chain(s), ❑ Dispenser Containment Float(s) and Chain(s). Dis enser ID: [Dispenser Dispenser ID: Conisinmcut Scnsvr(s). Model- ❑ Dispenser Cmtainmcnt Scnsor(s). Model: hear Valve(s). _ ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s)- *If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment Identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e g. manufacturers' checklists) necessary to verify that this information is correct and a ;gite-,);Lcd_Plan showing the layout of monitoring a uipment. For any eq ment capable of generating such reports, I have f also attached a copy of the report; (check ail that apply): Lj System set-up Alarm history report ;hnician Name (print): Luis Torres Signature: Certification No.: 842419 License. No.: Testing Company Name: Donlee Ptimp Company Phone No.: X209 537-9396 Testing Company Address: 2825 Railroad Ave Ceres CA. 95307 Date of Testing/Servicing: 3/13/2014 UN -W — 1/6 www.unidocs.org Rev. 01/17/08