COMPLIANCE INFO_FILE 12 - Laserfiche WebLink

Home Browse Search

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 Model: Mag I Bldg. No. 879 Site Address: Corral Hollow Road City: Tracy Zip: 95376 Facility Contact Person: Willie Smith Contact Phone No: (925) 423-0414 Make/Model of Monitoring System: Gilbarco EMC Date of Testing / Service: 10-20-2004 ❑ Electronic Line Leak Detector. Model: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: 879-G3U1 UNLEADED I Tank ID: 879-DIU1 DIESEL ■ In -Tank Gauging Probe. Model: Mag I ■ Annular Space or Vault Sensor. Model: 794390420 ■ Piping Sum / Trench Sensor(s). Model: 794380-205 ❑ 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 ■ hi -Tank Gauging Probe. Model: Mag 1 ■ Annular Space or Vault Sensor. Model: 794390-420 ■ Piping Sum / Trench Sensor(s). Model: 794380-205 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model.- odel:❑ LlElectronic Line Leak Detector. Model: ❑ Tank Overfill / Hi -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Pae 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 ❑ hi -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 Pae 2) Dis eraser ID: UNLEADED 1-2 Dispenser ID: DIESEL 5 ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). I Model: ■ Shear Valves . ■ Shear Valve(s). E Dispenser Containment Float(s) and Chain(s). ■ Dispenser Containment Float(s) and Chain(s). Dis enser ID: UNLEADED 3-4 Dispenser ID: ❑ Dispenser Containment Sensor(s). I Model: ❑ Dispenser Containment Sensor(s). I Model: ■ Shear Valves . ❑ Shear Valve(s). ■ Dispenser Containment Float(s) 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): IN System set-up ■ Alarm history report Technician Name: Brian Thornton Signature: - Certification No. 0348 License No. 724513 Testing Company Name: Thornton Environmental Construction, Inc. I Phone No. (408) 946-1015 Page 1 of 3 03/01