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NED a� Appendix VI y �� (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http:lh Wa� rrb?aI?.ca.gov.) N010NI i OIRiNv 0" S i BA CERT RCA i I01#NvIR0NMFNr'AL IiEALTH For Use By All Jurisdictions Within the State of California PERM /SLKVI0ES Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system ownerioperator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: VILLAGE WEST MARINA Bldg.No.: Site Address: 6649 EMBARCADERO DRIVE City: STOCKTON Zip: 95219 Facility Contact Person: TIM FONTAINE Contact Phone No.: 209 951-1551 ma4e,Model of Monitoring System: TLS 350 Date of Testing/Servicing: 03 L 16 L2017 B. Inventory of Equipment Tested/Certified Check the approEriate boxes to indicate sg2ciamuiMent ins ectediserviced: rTank ID: TANK 1 Tank ID: TANK 2 n-Tank Gauging Probe. Model: = In-Tank Gauging Probe. Model: nnular Space or Vault Sensor. Model: OPTICAL 433 V/R R Annular Space or Vault Sensor. Model: OPTICAL 433 V/R iping Sump/Trench Sensor(s). Model: 208 M Piping Sump/Trench Sensor(s). "-.node!: 208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: R Mechanical Line Leak Detector. Model: LD2000 R Mechanical Line Leak Detector. Model: LD2000 Electronic Line Leak Detector. Model: - Electronic Line Leak Detector. Model: a Tank Overfill/High-Level Sensor. Model: DROP TUBE VALVE E, Tank Overfill/High-Level Sensor. Model: DROP TUBE VALVE Other speFa equipment type and model in Section E on Page 2. Other s ea equipment t e and model in Section E on Page 2). Tank ID: Tank ID: In-Tank Gauging Probe. Model: - In-Tank Gauging Probe. Model: M Annular Space or Vault Sensor. Model: P iping Sum /Trench Sensor(s). Model: Annular Space rs\!m It Cpn"Jr i Adel p g pPiping Sump/Trench Sensor(s). Model: l Sump Sensor(s). Model: - Fill Sump Sensor(s). Model: echanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Line Leak Detector. Model: - Electronic Line Leak Detector. Model: ii nk Overfill/High-Level Sensor. Model: - Tank Overfill/High-Level Sensor. Model: hers ciequipment and model in Section E on Pa e 2. - Other(spe2a e ui ment a and model in Se=Pape Dispenser ID: 1 PREMIUM Dispeaca-IB: MANUAL VALVE SHUT OFF SUMP R Dispenser Containment Sensor(s). Model 208 R Disrpa�Containment Sensor(s). Model: 208 R Shear Valve(s). Shear Valve(s). Dispenser Containment Floats and Chains . _ Dispenser Containment Floats and Chain(s). Dispenser ID: 2 PREMIUM Disimmsef4l): PIPING TRANSITION SUMP R Dispenser Containment Sensor(s). Model: 208 ® Dispenser Containment Sensor(s). Model: 205 R Shear Valve(s). - Shear Valve(s). Dispenser Containment Floats and Chain(s). - Dispenser Containment Floats and Chain(s). Dispenser ID: 3 DIESEL Dispenser ID- 0 Dispenser Containment Sensor(s). Model: 208 - Dispenser Containment Sensor(s). Model: R Shear Valve(s). Shear Valve(s). Li Dis penser Containment Floats and Chain(s = Dispenser Containment Floats 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'checklists)necessary�Q verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generatt"hg such reports,I have also attached a ccpy of the repo (check aF°::rat apply): tai System set-up R Alarm history report GREG KAISER Signature: Technician Name(print): F Certification No.: A26983 License.No.: 859 6 Testing Company Name: KAISER COMMERCIAL PETROLEUM Phone No.: 2( 09 ) 887-2639 Testing Company Address: P.0.BOX 1058 LINDEN CA 95236 Date of Testing/Servicing: 03 / 16 / 2017 Mn nttsring System Certification Page! 0i4 12/07 1 2/21/07