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Ma.r, 18, 2014 2:CPM Doul Iumo Co, No. 6819 P. 2 MONAORING SYSTEM CERTIR ' ' TION Use By All Jurisdictions Within the State of Cal#,_,ia Authority Cited.- Chapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, Cali ornia CodEp Regulatlgy This form must be used to document testing and servicing of monitoring equipment. tie aei t� A scnaratc certification or rcoort must be prepared for each monitoring _m m control ;ng1 byt e tee icisn who performs the work A copy of this form must be provided to the tank system owncr/operator. The owner/operator must submit a copy of this form to the local agency regulating usr systems within 30 days of test date. M A R 18 2014 A. General Information ENVIRONMENTAL HEALTH Facility Name: Village west Marina DEP T�I�RIT Site Address: 6649 Embareadero City: Stockton Zip: 95219 Facility Contact Person: Chris Contact Phone No.: (209) 951-1551 Make/Model of Monitoring System: TLS -350 Date of Testing/Servicing: 311312014 B. Inventory of Equipment Tested/Certified Cheek the appropriate boxes t0 indicatt sneeif a [duipment insnerirri/VrrvirPd Tank ID: Tank iD: t — rt -Tank Gauging Probe_ Model: 414 In -Tank Gauging Probe, Model; q i RAnnular Space or Vault Sensor. Model: EArmular Space or Vault Sensor. Modal: Piping Sump / Trench Sensor(s). Model: [�iping Sump! Trench Sensor(9). Model; MAC ❑ Fill Sump Scnsor(s), Model: ❑ Fill Sump Sensor(s). Model; 2Nechanical Linc Leak Detector, Model: J:rMechanical Line leak Detector_ Model; ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Modcl; Tank Overfill / High -Level Sensor. Model: ' ,� ff3 ank Overfill I High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank TD: TanklA_ ❑ In -Tank Gauging Probe. Model: ❑ in -Tank Gauging Probc. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor, Model; ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Scnsor(s). Model: ❑ Fill Sump Sensor(s)_ Model: ❑ Fill Sump Scnsmts), Model; — ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Lcak Detector, Model; ❑ Electronic Line Leak Detector. Model: ❑ Flectronic Linc Leak Dctcctor. _ Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type sad model in Section L' on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Dispenser ID: Dispenser ID: Mtspcnscr Containment Scnyor(s). Modci: ❑ Dispenser Containment Sensor(s)_ Model: Shear Valve(s). ❑ Shcar Valvc(s). 1 ] Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser ID: (spcnser Containment Scnsor(s). hear Model: ❑ Dispenser Containment Sensor(s). Model: [� Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) and Chain(s). Diiss enser ID: Dispenser ID: l54 D�ispcnsk r Containment Scnsor(s). Model 71 Dispenser Contaimnent Sensor(s). Model: l�hcar Valvc(s). ❑ Shear Valve(s). ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). a the ractnty contains more tanks or dispensers, copy this toren. 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 Sfte-EL&Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): a System set-up ❑ Alarm history report Technician Name (print): Luis Torras Signature: _ Certification No.: B42419 License. No.: Testing Company Name: Donlee Pump Company Phone No.: (209) 537.9396 Testing Company Address: 2825 Railroad Ave Ceres, CA. 95307 Date of Testing/Servicing. 3/13/2014 UN -036 -1,16 www.unidocs org Rev. 01/17/08