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Jul 11 05 10:22p Mike Dotten 112091 533-2650 p.1 17759 Buttercup Circle, Sonora, CA 95370 W Phone: 209-532-7320; Fax: 209-533-2650 California Contractor 623541 A-Haz alltech@getrocket.com MONITORING SYSTEM CERTIFICATION A. General Information Facility Name: Village West Marina Date of Testing/Servicing: July 8, 2005 Facility Address: 6649 Embarcadero 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 3501 This test report is o• 151 Final Report (Facility was observed to be in Compliance) or a: ❑ Preliminary Report (Unresolved Issues Esist) B Inventory of Equipment Tested/Certified: C. Certification - I certify that the evipment identified in this document was inspectedfserviced 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 r.., tai. — nus . KSI 4 1.. ... 1.Ccln.�r rnr,nr4 epotts, l cave atsu au.� _ .. _ :,: t. u.. r, _. Technician: ; Mike Dotten, California Contractor License. No.: 623541 Certification: Veeder-Root:006-05-0789 ; Level 4. ICC UST Service Technician # 5259412 -UT. Page 1 of 3 03101 Task ID: Regular Tank Tank ID: Diesel Tank ❑ In -rank Gaub;+:b .:.,,:.. r-1 1_ 'r-,-)- /'.......:n.. AgnAol �Tpne. ® Annular Space or Vault Sensor. Model: V -R Mini Sensor ® Annular Space or Vault Sensor. Model: V -R Mini Sensor l ® 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: ® 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 Overfill / High -Level Sensor. Model: Drop Tube ® Tank Overfill / Nigh -Level Sensor. Model: Drop Tube ❑ Other ❑ Other Tank ID: Tank m: ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: D 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 Settsor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill/ IIigh-Level Sensor. Model: ❑ Tank Overfill / Iligh-Level Sensor. Model: ❑ Other ❑ Other Dispenser ID: I N Sump: ®Dry ❑Water ❑Product Dispenser ID: 2 ® Sump: ®Dry ❑Water []Product ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ® Shear Valve(s) (Functional test) ® Shear Valve(s) (Functional test) ® Dis eraser Containment Floa&2 and Chain(s). E Dis -user Containment Floats and Chain(s). Dispenser ID: 3 ® Sump: ®Dry ❑Water FlProduct Dispenser ID: ❑ Sump: ❑Dry []Water Product ❑ Dispenser Containment Sensor(s). Mouel: ❑ Dispenser Containment Sensor(s). Model. ® Shear Valve(s) (Functional test) ❑ Shear Valve(s) (Functional test) ® Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Flo! s and Chain(s). 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 Floats) and Chain(s). ❑ Dispenser Containment Float(s) and Chain(s). C. Certification - I certify that the evipment identified in this document was inspectedfserviced 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 r.., tai. — nus . KSI 4 1.. ... 1.Ccln.�r rnr,nr4 epotts, l cave atsu au.� _ .. _ :,: t. u.. r, _. Technician: ; Mike Dotten, California Contractor License. No.: 623541 Certification: Veeder-Root:006-05-0789 ; Level 4. ICC UST Service Technician # 5259412 -UT. Page 1 of 3 03101