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ME/VE MAR3 ENS, ° 2016 Appendix VI PROIyUE (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.wa , ' SES Ty MONITORING SYSTEM CERTIFICATION For Use 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 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 owner/operator. 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 Make/Model of Monitoring System: TLS -350 Date of Testing/Servicing: 03 / 16 / 2016 B. Inventory of Equipment Tested/Certified .�_ appropr;.,a.. L.....ac M inrlirmfn cnerifiC anuinmPnt incnPctedlserviced: Check thia— Tank ID. TANK 1 Tank ID: TANK 2 In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: ® Annular Space or Vault Sensor. Model: OPTICAL 433 V/R ® Annular Space or Vault Sensor. Model: OPTICAL 433 V/R ® Piping Sump / Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: LD2000 ® Mechanical Line Leak Detector. Model: LD2000 ii Electronic Line Leak Detector, Model: Electronic Line Leak Detector. Model: Tank Overfill /High -Level Sensor. Model: DROP TUBE VALVE Tank Overfill (High -Level Sensor. Model: DROP TUBE VALVE 1 Others eci a ui ment type and model in Section E on Pae 2 . L nthpr (sn.-rifv e ui ment t e and model in Section E on Pae 2). Tank ID: Tank ID: In -Tank Gauging Probe. Model In -Tank Gauging Probe. Model: is Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model: L i Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: I 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: k Overfill / High -Level Sensor. Model: - Tank Overfill / High -Level Sensor. Model: er s eci a ui ment t e and model in Section E on Pa e 2 . Others eci e ui ment t e and model in Section E on Pa e 2 .ser ID: 1 PREMIUM Dispenser! : MANUAL VALVE SHUT OFF SUMP penser Containment Sensor(s). Model: 208 ® Dispen6er Containment Sensor(s). Model: 208 ar Valve(s). Shear Valve(s). enser Containment Floats and Chains . Dispenser Containment Float s) and Chain(s). nser ID: 2 PREMIUM IDis Dispenser -ID: PIPING TRANSITION SUMP penser Containment Sensor(s). Model: 208 ® Bi6peaser Containment Sensor(s). Model: 205 ear Valve(s). Shear Valve(s). enser Containment Floats and Chains . Dis enser Containment Float(s) and Chain s). nser ID: 3 DIESEL Dispenser ID:penser Containment Sensor(s). Model: 208 Dispenser Containment Sensor(s). Model: ear Valve(s). Shear Valve(s). enser Containment Floats and Chains Dispenser Containment Float(s) and Chain(s). *If the facility contains more tanks or dispensers, copy this form Include information for every tank ana dispenser at the taciiiiy. 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 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 Name (print): GREG KAISER Signature: Certification No.: A25983 License. No.: 85953 Testing Company Name: KAISER COMMERCIAL PETROLEUM Phone`No.: 2( 09 ) 887-2639 Testing Company Address: P O. BOX 1058 LINDEN, CA 95236 Date of Testing/Servicing: 03 / 16 / 2016 Monitoring System Certification Page 1 of 4 12/07 2/21/07