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n 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. Generallnformatinn B. Inventory of FaninmentTented/Certified Check the appropriate boxes to indicates chic equipment ins cted/serviced: Tank ID: DIESEL 871-D1U2 I Tank ID: ■ In -Tank Gauging Probe. Facility Name: Lawrence Livermore National Laborawy Site 300 1 Bldg. No. 871 Model: 420 ■ Piping Sum / Trench Senso s . Site Address: Corral Hollow Road City: Trac I Zip: 95376 Model: ❑ Mechanical Line Leak Detector. Facility Contact Person: Willie Smith Contact Phone No: (925) 423-0414 ❑ Electronic Line Leak Detector. Model: Make/Model of Monitoring System: Veeder-Root TLS -350 Date of Testing / Service: 10-28-2003 Model: B. Inventory of FaninmentTented/Certified Check the appropriate boxes to indicates chic equipment ins cted/serviced: Tank ID: DIESEL 871-D1U2 I Tank ID: ■ In -Tank Gauging Probe. Model: Mag 1 ■ Annular Space or Vault Sensor. Model: 420 ■ Piping Sum / Trench Senso s . Model: 205 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2 ❑ In -Tank Gaugipj Probe. Model: ❑ Annular S ace or Vault Sensor. Model: ❑ Pi2ing Sum / Trench Sensor(s). Model: D Fill SumR Sensor(s). Model: 13 Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / Hi -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on P e2 Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sum / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ® Tank Overfill / Hi -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on P e2 ❑ In -Tank Gauging Probe. Model: O Annular Space or Vault Sensor. Model: ❑ Piping Sum / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / Hi -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2 Dis enser ID: NO DISPENSERS Dis enser ID: ❑ Dispenser Containment Sensor(s). I Model: ❑ Dispenser Containment Sensor(s). I Model: Shear Valve(s). ® Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ® Dispenser Containment Floats and Chain(s). Dispenser ID: ispenser ID: ❑ Dispenser Containment Sensor(s). I Model:❑ Dispenser Containment Sensor(s). Model ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chains . ❑ 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 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 cony of the renort: (check all that annlvl: ❑ Svstem set -un ❑ Alarm history renort Technician Name: Brian Thornton Si tures - Certification No. 0348 License No. 724513 Testing Company Name: Thomton & Son Electric 408 946-1015 L--:," Page 1 of 3 Nov 1 zoo EN�IRC�Nt��N� HCko " PERMITISERVt 03101