COMPLIANCE INFO_FILE 14 - Laserfiche WebLink

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0 0 MONITORING SYSTEM CERTIFICATIOPEGEIVED for Use By All Jurisdictions Within the State of California Afi 27 2018 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code i;f egu ations '[In-, forni must be used to document testing and servicing of monitoring equipment. A separate certification or re ort $ tUAVQMach monitoring system_control panel by the technician who perforans the work. A copy of this form must beDt s oner/operator. Thee owner/operator must submit a copy of this form to the local agency regulating UST wit,OR,IN", P r fftRT w A. General Information Facility Name: - Lawrence Livermore National Laboratory Site 300 Bldg. No.:B882 Site Address: -Corral Hollow Road City: Tracy Zip: 95376 Facility Contact Person: hyllis ox Contact Phone No.: (925) 423-9658 Make/Model of Monitoring System.- USD Leak Alert LA-02 Date of Testing/Sen,icing:7-,,,_3Q28 B. Inventory of Equipment Tested/Certified Check the appro Hate boxes to Indicate specific eguipstent ImZ=ed/servIced: Tank ID: 882-TFUDOI Diesel Tank ED: ❑In-Tank Gauging Probe. Model: El In-Tank Gauging Probe- Model: Annular Space or Vault Sensor. Model: LALS-1 El Annular Space or Vault Sensor. Model: Piping Sump "french Sensor(s). Model: LALS-1 Piping Sump Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: E]Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector, Model: Ej Electronic Line Leak Detector. Model- El Electronic Line Leak Detector. Model: ❑Tank Overfill Iligh-Level Sensor, Model: [I Tank Overfill Ifigb-Level Sensor, Model: ❑Other(specify equipment type and model in Section E on Page 2). Other(specify equipment type and model in Section E on Page 2). Tank tD: Tank ID: El In=Tank Gauging Probe. Model: [I In-Tank Gauging Probe. Mode]: [I Auinular Space or Vault Sensor. Model: El Annular Space or Vault Sensor, Model: [I Piping Sump 'French Sensor(s). Model: [I Piping Sump Trench SLnscrr(s). model: El Fill Sump Sensor(s). Model: C3 Fill Sump Sensor(s). Model 0 Mechanical Line Leak Detector. Model- C1 Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: []Ftedronic Line Leak Delector. Model: ❑Tank Overfill High-Level Sensor. Model: El Tank Overfill High-level Sensor. Model: n Oflia(specify equipment type and model in Section E on Page 2). El Other(specify equipment type and model in Section r on Page 2). Dispenser ID: N0 DISPENSERS Dispenser ID: E]Dispenser Containment Sensor(s). Model: 0 Disperser Containment Sensor(s). Model: El Shear Valve(s). 0 Shear Valve(s). C]Dispenser Containment Float(s)and Chain(s). El Dispenser Containment Floal(s)and Chain(s). Dispenser ID: Dispenser ED: El Dispenser Containment Sensor(s)- Model: 0 Dispenser Containment Sensor(s). Model - El Shear Valve(s), C3 Shear Valve(s). [I Dispenser Containment Float(s)and Chain(s). C]Dispenser Containment Floal(s)and Chain(s). Dispenser ID: Dispenser ID: El Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s), Model: E3 Shear Valve(s). El Shear Valve(s). ❑Dispenser Containment Floats)and Chain{s). ❑Dispenser Containment Floal(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this flann. 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): 0 System set-up RAla rin history report ................... Technician Name Brian Thornton Signature:1 2.5- Certification No.: 8-0472 — License.No.: 724513A, C-10, HAZ ICC#5024962-UT— Testing Company Name: Thornton Environmental Construction, Inc. — Phone No.:(209) 834-0792 Testing Company Address:PO Box 360833 Milpitas,CA 95039 —Date ofTesting/Servicing: 7-30-2018 Page I of 3 ESH-EFA-TKS-18-15666-SM/EM:mw