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Alltech Petro Inc. <br /> 17759 Buttercup Circle, Sonora, CA 95370 <br /> Phone: 209-532-7320; Fax: 209-533-2650 <br /> California Contractor 623541 A-Haz <br /> alltechmail@me.com <br /> MONITORING SYSTEM CERTIFICATION <br /> A. General Information <br /> Facility Name:Village West Marina Date of Testing/Servicing:April 3,2009 <br /> Facility Address:6649 Embarcadero Drive,Stockton CA 95217 <br /> Facility Contact Person: Mike Spence Contact Phone No.:209-951-1551 <br /> Regulatory agency:San Joaquin Health;Inspector:Garrett Backus;Phone:468-9847;Fax 468-3433. <br /> Make/Model of Monitoring System:Veeder-Root TLS 3501 <br /> B. Inventory of Equipment Tested/Certified: <br /> Tank ID. Premium Tank Tank ID: Diesel Tank <br /> ❑In-Tank Gauging Probe. Model:None ❑In-Tank Gauging Probe. Model:None <br /> ®Annular Space or Vault Sensor. Model:794380-344 ®Annular Space or Vault Sensor. Model:794380-344 <br /> ®Piping Sump/Trench Sensor(s). Model:794380-208 ®Piping Sump/Trench Sensor(s). Model:794380-208 <br /> ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: <br /> ®Mechanical Line Leak Detector. Model:VMI LD-2000 ®Mechanical Line Leak Detector. Model:VMI LD-2000 <br /> ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: <br /> ®Tank Overfill/High-Level Sensor. Model:Drop Tube ®Tank Overfill/High-Level Sensor. Model:Drop Tube <br /> ❑Other ❑Other <br /> Tank ID: Tank ID: <br /> ❑In-Tank Gauging Probe. Model: ❑In-Tank Gauging Probe. Model: <br /> ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: <br /> ❑Piping Sump/Trench Sensor(s). Model: ❑Piping Sump/Trench Sensor(s). Model: <br /> ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: <br /> ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: <br /> ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: <br /> ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: <br /> ❑Other ❑Other <br /> Transition Sump: ®Sump:®Dry[]water❑Product Dispenser ID: ❑Sump:❑Dry❑Water❑1'roduct <br /> E Sump Containment Sensor(s). Model:794380-208 ❑Dispenser Containment Sensor(s). Model: <br /> ❑Shear Valve(s) (Functional test) ❑Shear Valve(s) (Functional test) <br /> ❑ <br /> Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). <br /> Dispenser ID: 1 ® Sump:®Dry❑Water❑Product Dispenser ID:2® Sump:®Dry❑Water❑Product <br /> ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: <br /> ®Shear Valve(s) (Functional test) ®Shear Valve(s) (Functional test) <br /> ®Dispenser Containment Float(s)and Chain(s). ®Dispenser Containment Floats and Chain(s). <br /> Dispenser ID:3® Sump:®Dry❑Water❑Product Dispenser ID: ❑Sump:❑Dry❑Water[I Product <br /> ❑Dispenser Containment Sensor(s). Model: ❑Dispenser Containment Sensor(s). Model: <br /> ®Shear Valve(s) (Functional test) ❑Shear Valve(s) (Functional test) <br /> ®Dispenser Containment Floats and Chain(s). ❑Dispenser Containment Float(,)and Chain(s). <br /> C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the <br /> manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this <br /> information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such <br /> reports,1 have also attached a copy of the report;(check all that apply): ❑System set-up ❑ Alarm history report <br /> Page 1 of 3 03/01 <br /> Technician: Date: 4/3/09 <br /> Certitication:Veeder-Root B36878,Level 2/3 <br /> ICC UST Service Technician#8005930-UT <br />