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t 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 Laboratory Site 300 Bldg. No. 879 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 Gilbarco EMC Date of Testing / Service: 10-23-2003 B. Inventory of EquipmentTested/Certified Check the appropriate boxes to indicates cific equipment ins cted/serviced: Tank ID: UNLEADED Tank ID: DIESEL ■ In -Tank Gauging Probe. Model: Mag 1 ■ Annular Space or Vault Sensor. Model: 420 ■ Piping Sum / Trench Sensor(s). Model: 205 ❑ Fill Sump Senso s . Model: O Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Pae 2 ■ In -Tank Gauging Probe. Model: Mag I ■ 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 / Iii -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Pa 2 Tank ID: Tank ID• ❑ In -Tank Gauging Probe. Model: Q Annular Space or Vault Sensor. Model: ❑ Piping Sum / Trench Senso s . Model: ❑ Fill Sump Senso 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 ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sum / Trench Sensor(s). Model: ❑ Fill Sum Senso s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / Hi -Level Sensor. Model:. O Other (specify equipment type and model in Section E on Page 2 Dispenser ID: UNLEADED 1-2 Dispenser ID: DIESEL 5 ❑ Dispenser Containment Sensor(s). 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). Dis eraser ID: UNLEADED 34 Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ® Dispenser Containment Senso s . Model: ■ Shear Valve(s). ❑ Shear Valve(s). ■ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chains . *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 lavout of monitoring euuipment. For unv eouimnent capable of generating such reports. I have also attached a copy of the report, (check all that apply): ■ S stem set-up ■ Alarm history report Technician Name: Brian Thornton Signature: , Certification No. 0348 License No. 724513 Testing Company Name: Thornton & Son Electric I Phone No. 408 946-1015 Page I of 03/01