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RECEIVErj Appendix VI APR 0 9 2015 (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at ttttp://wvfw.waterboards.ca.gov.) ENVIRONMENTAL HEALTH MONITORING SYSTEM CERTIFICATION PERMIT/SERVICES 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 / 2015 Inventory of Equipment Tested/Certified Check theappropriate ovxes w indicate speciiw may„ N ID: TANK 1 Tank ID: TANK 2 In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: [Tank Annular Space or Vault Sensor. Model: OPTICAL 433 VIR ® Annular Space or Vault Sensor. Model: OPTICAL 433 VIR Piping Sump /Trench Sensor(s). Model: 208 ® Piping Sump / Trench Sensor(s). Model: 208 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model: M Mechanical Line Leak Detector. Model: LD2000 ® Mechanical Line Leak Detector. Model: LD2000 ❑ Electronic Line Leak Detector. L' Tank Overfill / High -Level Sensor. Model: Model: DROP TUBE VALVE Electronic Line Leak Detector. Model: _ Tank Overfill / High -Level Sensor. Model: DROP TUBE VALVE C Other s ecify a ui ment t e and model in Section E on Pa e 2 . Other s eci equipment t e and model in Section E on Pa e 21. TanklD: TanklD: In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model: ❑ 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: u Electronic Line Leak Detector. Model: = Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: - Tank Overfill / High -Level Sensor. Model: ❑ Other s eci a ui ment type and model in Section E on Pa e 2 . Other(specifyequipment t e and model in Section E on Pae 2). Dispenser ID: 1 PREMIUM 9ispenseF-IB: MANUAL VALVE SHUT OFF SUMP ® Dispenser Containment Sensor(s). Model: 208 ® Pi6penser Containment Sensor(s). Model: 208 ® Shear Valve(s). Dis enser Containment Floats and Chain(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser ID: 2 PREMIUM 9ispenser 18: PIPING TRANSITION SUMP ® Dispenser Containment Sensor(s). Model: 208 ® 966penser Containment Sensor(s). Model: 205 ® Shear Valve(s). t_ iDis enser Containment Float(s) and Chain(s). __ Shear Valve(s). _ Dis enser Containment Float(s) and Chain(s). Dispenser ID: 3 DIESEL ® Dispenser Containment Sensor(s). Model: 208 Dispenser ID: Dispenser Containment Sensor(s). Model: ® Shear Valve(s). Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Dispenser Containment Floats and Chains -If the facility contains more tanks or dispensers, copy this form. include intormauon Tor every ranK dnu UlbPtinser at Lite ta—uy. 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) necessa to verify that this information is correct and a Plot Plan showing the layout of monitonn�equipment. For aryc equipment capable o 'gen _ting such reports, I have also attached a copy of the report; (check all that apply): ?� System set-up Alarm historyAreport Technician Name (print): GREG KAISER Signature: Certification No.: A25983 License. No.Testing Company Name: KAISER COMMERCIAL PETROLEUM : 209 1 887-2639 Testing Company Address: P. O. BOX 1058 LINDEN CA 95236 Date of Testing/Servicing: 03 / 16 / 2015 Monitoring System Certification Page 1 of 4 12107 2/21/07