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Ma r. 26. 2013 10:36AM Donlee Pump Co. hd:.2172 2 MON. 3RING SYSTEM CERTIFIATYGN For U.se By All Jurisdictions Within the State of California Authority Cited:- Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code ofReg7dations T.'bis form must be used to document testing and servicing of monitoring equipment, if +,^n one „,eaAerin .System entFal tkaeilitg a A separate certification ar report muM be poled for each monitoringsysbcm control panel by the techn' A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of Fqeo regulatingUST systems within 30 days of test date.4-»*+,e +^^ct. of!";., A. General Information MSP 2 6 2013 FaciJityName: Village West Marina 9:4 �J� MENTAL Site Address: 6649 Embarcadero Drive City: Stockton Zip: 6`JjgAR�tVT Facility Contact Person: Contact Phone No.: (209) 951-1551 Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 3118/2013 B. Inventory of Equipment 'Tested/Certified Check the approgriate boxes to indicate s eelfle equipment ins ected/scrvicedt 'Conk to: 0P%kO A pie tM �uhs Tank ilD: Rj k Di£^ye` _ - NO Annular Space or Vault Sensor. Model: Annular Space or Vault Scissor. Model: Piping Sump / Trench Sensor(s). Model: 20 Piping Sump / Trench Senso?(s), Model: j0$ ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Modell fikMechanical Line Leak Detector. Model: V—ALL&Q50 _ Mechanical Line Leak Detector. Modcl: U a ❑ Electronic Line Leak Detwfor, Model; ❑ Electronic Line Leak Detector. Model: ' .Tank Overfill / High -Level Sensor, Model: dpi M &4,d ft! CAI Tank Overfill / High-] evel Sensor. Mcdcl; Q�Q MyoekaA oA 1 ❑ Other (specie equipment type and model in Scction E on Page 2). ❑ Other (4pccifv equipment type and model in Section E on Page 2). Tank )P: _ Tank ID: ❑ In -Tank Gauging Probc. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor- Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Scnsor(s). Model: _ ❑ Fill. Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: _ ❑ Mechanical Line Leak Detector. Memel; 9 ❑ Electronic Line Leak Detector- Model: ❑ Electronic Line Leak Deteehx. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill 1 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). Dispenser ID: Dispenser TD: :— ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s), Model: IN Shear Valve(s), Shear Valve(s), Dispenser Containment Roat(s) and Chain(s). p Dispenser Containment Floats) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispcnsor Containment Sensor(s). Model: Shcar Valvc(s). C1 Shear Valvc(s). Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment float(s) and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model; ❑ Dispenser Containment Sensor(s). Model: ❑ Shear 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' checktigts) necessary to verify that this information is correct and a site -Plot Platt showing the layout of monitoringa uipment- For any equipment capable of generating such reports, 1[have also attached a copy of the report; (check all that apply): System set-up Alarm history report Technician Name (print): Bryan Mitchell Signature: Certific,ation Nq,; B34545 License. No.: 5293476 -UT Testing Company Name: Donlee Pump Company Phone No.: (209) 537-9396 Testing Company Address: 2826RailroadAve Ceres, CA. 95307 Date ofTesting/Servicing: 311 812 01 3 UN -036 —1/6 www,auidocs.org Rev. 01/17/08