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Nvv 25 06 08:50p Mike Dotten 209-533-2650 p.1 A1ltech 17759 Buttercup Circle, Sonora, CA 95370 Phone: 209-532-7320; Pax: 209-533-2650 California Contractor 623541 A-Haz allteetrocket.com MONITORING SYSTEM CERTIFICATION ILI A. General Information Facility Name: Village West Marina Date of Testing/Servicing: April 4, 2006 Facility Address: 6649 Embareadero Drive, Stockton CA 95217 Facility Contact Person: Mike Spence Contact Phone No.: 209-951-1551 Regulatory agency: San Joaquin Health; Inspector: Michelle Le ; Phone: 468-9847; Fax 468-3433. Make/Model of :Monitoring System: Veeder-Root TLS 3501i This test report is a: ® Final Report (Facility was observed to be in Compliance) or a: ❑ Preliminary Report (Unresolved issues Exist) B. Inventory of Equipment Tested/Certified: Tank ID: Regular Tank Tank ID: Diesel Tank ❑ In -Tank Gauging Probe. Model: None ❑ In -Tank Gauging Probe. Model: None ® Annular Space or Vault Sensor, Model: V -R Mini Sensor ® Annular Space or Vault Sensor. Model: V -R Mini Sensor ® Piping Sump / Trench Sensor(s). Model: Float Switch ® Piping Sump / Trench Sensor(s). Model: Float Switch ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s), Model - 0 Mechanical Line Leak Detector. Model: Red Jacket Diaph. ® Mechanical Line Leak Detector, Model: Vaporless LD -2000 ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank OverfilI / High -Level Sensor. Model: Drop Tube ® Tank Overfill I High -Level Sensor. Model: Drop Tube ❑ Other ❑ Other 'rank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. tilodcl: ❑ 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 Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other ❑ Other Dispenser ID: 1 ® Sump. ®Dry ❑Water ❑Product Dispenser ID: 2 ® Sump: ®Dry El water ❑Product []Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s) (Functional test) N Shear Valve(s) (Functional test) ® D' nser Containment Floats and Chain(s). ® DiTenser Containment Float(s) and Chain s). Dispenser 113: 3 ® Sump: ®Dry ❑Waxer ❑Product Dispenser ID: ❑ Sump: ❑Dry ❑Water ❑Product ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Slim Valve(s) (Functional test) ❑ Shear Valve(s) (Functional test) ® Dispenser Containment Floats and Chain(s). ❑ Di eraser Containment Float(s) and Chains . Dispenser ID: ❑ Sump: ❑Dry []water ❑Product Dispenser ID: ❑ Sump: ❑Dry ❑Water ❑Product ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s) (Functional test) ❑ Shear Valve(s) (Functional test) ❑ Dispenser Containment Float(s) and Chain(s). ❑ Dispenser Containment Floats) and Ch ' s . C. Certification - I certify that the equipment identified in this document was inspectedlserviced 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 Plot 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): ® System set-up ® Alarm history report Technician: y r Mike Dottea, California Contractor License. No.: 623541 Certification: Veeder-Root:006-05-0789 ; Level 4. ICC UST Service Technician P 5259412 -IIT. Page 1 of 3 03/01