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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: Lawrence Livermore National Labomtory Site 300 Model: Mag 1 31dg. No. 875 Site Address: Corral Hollow Road City: Trac Zip: 95376 Facility Contact Person: Willie Smith Contact Phone No: (925) 423-0414 Make/Model of Monitoring System: Veeder-Root TLS -350 Date of Testing / Service: 10-28-2003 B. Inventory of Equipment'Tested/Certified Check t e aeeroLnate boxes to indicates cific a ui ment ins cted/serviced: Tank ID: DIESEL 875-DIU2 I Tank ID: ■ In -Tank Gng Probe. Model: Mag 1 ■ Annular Space or Vault Sensor. Model: 420 ■ Piping Sum / Trench Sensor(s). Model: 205 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High- I Sensor. Model: ❑ Other (specify equipment type and model in Section E on Pae 2 ❑ 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 2 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 / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2 ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sum / Trench Sensor(s). Model: ❑ Fill Sump Sensors . Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: E3 Tank Overfill / Hi -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on P 2 Dis eraser ID: NO DISPENSERS Dis enser ID: ❑ Dispenser Containment Sensors . I Model: ❑ Dispenser Containment Sensors Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dis enser ID: Dis enser ID: ❑ Dispenser Containment Sensor(s). I Model: ❑ Dis ser Containment Sensor(s). I Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser 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 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: Brian Thornton Si tune: Certification No. 0348 License No. 724513 Testing Company Name: Thornton & Son Electric I Phone No. 408 946-1015 Page 1 of 3 03/01