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0 0 RECEIVED MONITORING SVSTEM CERTIFICATION AUG 2 2 2018 For Use By A 11.1urisdictions Within the State of California Authority Cited: Chapter 6 7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Cody .�TAL This forin must be used to document testing and servicing of monitoring equipi I nent. A separate certification Or repo&"L%@WAPfbW T monitoring system control Danel 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.: B879 Site Address: -Corral Hollow Road City: Tracy Zip: 96376 Facility Contact Person: Phyllis Cox Contact Phone No.: (92 5) 423-9658 Make/Model of Monitoring System: Gilbarco EMC Date of Testing/Servicing: 7-30-2018 B. Inventory of Equipment Tested/Certified Check thea ea ate boxes to Idicote sgecifice i anent legal: Tank a 879-TFUGOI Unleaded Tank ID: 879-TFUDOI Diesel CD In-Taal:Gauging Probe. Model: mag 1 0 In-Tank Gauging Probe. Model: Mag I 0 Annular Space or Vault Sensor, Model: 794390-420 0 Annular Space or Vault Sensor- Model: 794390-420 0 Piping Stamp Trench Sensor(s). Model: 794380-206 0 Piping Sump Trench Sensor(s). Model: 794380-206 El Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: 0 Mechanical Une Leak 1)eleoor. Model: SSLD2m meenanicai Line uaf,Ymecaur. mod&. E]Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: El Tank Overfill High-Level Sensor. Model: ❑'rank Overfill High-Level Sensor. Model: El Other(specify equipment type and model in Section E on Page 2). Other(a;pec ify,equipment type and model in Section E on Page 2). Tank ID: Tank[ID: El In-Tank Gauging Probe. Model: El hi-Tank Gauging Probe. Model: Ej Annular Space or Vault Sensor. Model: C1 Annular Space or Vault Soisor. Model: El Piping Sump Trench Sensor(s). Model: Piping Sump Trench Sm-or(s). Model: El Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model ❑Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: El Electronic Line Leak Detector, Model: DTank Overfill High-Level Sensor. Model: 0 Tank Overfill High-Level Sensor, k4odel: E3Other(specify equipment type and model in Section E on Page 2). 1 El Other(specify equipment type and model in Section E on Page 2). Dispenser ID: Unleaded I Dispenser ID: ---- ---—----- D"Pen'er a 0 Dispenser Containment Sermr(,i) Model: Bravo ®Dispenser Containment Sensor(s). Model: 0, N e ') 'h r Valves}. alv_(, _� '_Con C 0 Shear Valve(s), V"'Ye") Dispenser i. Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). n e�aed 2 Di n er ID. Dispenser-ser ID: Unleaded 2 Dispenser-ID: 7 [II)ispctt-,erCojitai�nmentSensor(s). Model: Bravo El Dispenser Containment Sensor(s). Model: Shear Valve(s). El Shear Valve(s). Dispenser Containment Float(s)and Chain(s). C1 Dispenser Containment Float(s)and Chain(s). Dispenser ID. Diesel 3 Dispenser ID: El Dispenser Containment Sensor(s). Model: Bravo Dispenser Containment Sensor(s). Model: Shear Valve(s) Shear Valve(s). Dispenser Containment Float(s)and Chain(s). El Dispenser Containment Float(s)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 Signature: ,dam"01 Certification No.: A31562 License.No.: 724613 A, C-1 0, HAZ ICC#5024962-UT Testing Company Name: Thornton Environmental Construction, Inc. Phone No.:(209) 834-0792 Testing Company Address:PO Box 360833 Milpitas,CA 96036 Date of Testing/Servicing: 7-30-2018 Page I of 3 ESH-EFA-TKS-18-15666-SM/EM:mw