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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 Laboratory Site 300 Bld . No. 882 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: USD LA -02 Date of Testing / Service: 10-28-2003 B. Inventory of Equipment'Tessted/Certified Check the approLdate boxes to indicates cific aqui went ins cted/serviced: Tank ID: DIESEL 882-DIUI IT Tank ID: ❑ In -Tank ng Probe. Model: ■ Annular Space or Vault Sensor. Model: LALS-1 ■ Piping Sum / Trench Sensor(s). Model: LALS-1 ❑ Fill Sump Sensors). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Le I Sensor. Model: ❑ Other (specify equipment type and model in Section E on LENE2 ❑ In -Tank Gau 'n& Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ PipipA Sum / Trench Sensors). 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 Tank ID Tank ID: ❑ In -Tank Gaugipg GaugingProbe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Pipi2g Sum / Trench Semo s . Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / Hi -Level Sensor. d 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 Sino s . Model: ❑Fill Sump Sensos . 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 eraser 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). Dis enser ID: 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). *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 ennv of tho mnnrt- /check all that annlvl- ❑ Svctem set -eon ❑ Alarm hietory renort Technician Name: Brian Thornton Si tures s--- - "-----�.. Certification No. 02-0276 License No. 724513 Testing Company Name: Thornton &Son Electric Phone No. 408 946-1015 Page 1 of 3 03/01