COMPLIANCE INFO_FILE 12 - Laserfiche WebLink

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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 seoarate certification or report must be nrenared 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: Bldg. No. 882 Site Address: Corral Hollow Road City: Tracy I 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: 10-26-2004 ❑ Electronic Line Leak Detector. Model: B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicatespecific equipment ins ected/serviced: Tank ID: 882-DIU1 DIESEL Tank ID: ❑ In -Tank Gauging Probe. Model: ■ Annular Space or Vault Sensor. Model: LALS-1 ■ Piping Sum / Trench Sensor(s). Model: LALS-1 ❑ 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 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 Pa) Tank ID: Tank ID: II ❑ 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 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 Pae 2) Dispenser ID: NO DISPENSERS Dispenser ID: ❑ Dispenser Containment Sensor(s). I Model: ❑ Dispenser Containment Sensors). I Model: ❑ Shear Val v s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑Dis enser Containment Floats and Chain(s). Dis enser ID: Dispenser ID: ❑ Dispenser Containment Se (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 copy of the report; (check all that apply): ❑ Svstem set-up ❑ Alarm history report Technician Name: Brian Thornton Signature: _.. - -- Certification No. 02-0276 License No. 724513 Testing Company Name: Thornton Environmental Construction, Inc. I Phone No. (408) 946-1015 Page 1 of 3 03/01