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3 MONITORING SYSTEM CERTIF ICAUMNRAF-N'TPJ, "'�ALTK 1 --or Use Ltv A 11.1urisdictions Within the State of California D "P 'T JE _' j .4 tithoriti; Cited; Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California ET %refVgulaNtio"ns This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be preRared 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. flee owner/operator must Submit a copy of this form to the local agency regula(ing. UST systems within 30 days of test dale 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.: (926) 423-9658 Make/Model of Monitoring System: Gilbarco EMC Date of Test ing/Servicing: 7 3 0 018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate specific equilipment insiDected/serviced: Tank ED: 879-TFUG0I Unleaded Tank ED: 879-TFUDOI Diesel 0 lit -Tank Gauging Probe. Model: Mac: 1 0 In4ank Causing Probe. Model: Man I 0 Annular Space or Vault Sensor. Model: 794390420 19 An Space or Vault Sensor. Model: 794390420 0 Piping Sump Trench Scrisor(s). Model: 7-94380-206 19 Piping Sump 'Trench Sensor(s). Model: 794380-206 Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: Mcchanica) Line Leak Detector. MoftiD-2M 0 MecIiianical Line Leak Detector. MOW-. ❑ Electronic Line Leak Detector. !-lode!: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill High -Level Sensor. Model: El 'r" Overfill High -Level Sensor. Model: 0 Other (specify equipment type and model in Section E on Page 2). 0 Other (Wcc 4 equipment type and model in Section E on Page 2). Tank ED: Tank ED: 0 In -Tank Gauging Probe, Model: 0 In-l'ank Ganging Probe. Model: [I Nuiular Space or Vault Sensor, Model: 0 ,Utnular Space or Vault Sensor. Modcl: 0 Piping Sump Trench Sensor(s). Model! [I Piping Sump r TrcnchSeusw(s). Model: [I Fill Sump Sensor(s), Model: [3 Fill Sump Sensor(s). Model, ❑ Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: Electronic Line Leak- Detector. Model: 0 Electronic Line Leak Detector. Model:it ❑ Tank Overfill High -bevel Sensor. Model: C1 Tank Overfill High-level Sensor, Model: Q Other(specify equipment type and model in Section Eon Page 2). [1 Other (.specify cquiptnent type and model in Section E on Page 2). Dispenser ED: Unleaded I Dispenser ED: Dispenser Containment Sensorls) Model-. Bravo, 0 Dispenitet Containment Sensof(s), Model: Shear Valve(s) Q Shear Valve(s). Dispenser Containment Float(s) and Chain(s). Q [Nspcm%v Containment Float(s) and Chain(s) Dispenser ID: Unleaded 2 Dispenser ED: [I Dispenser Containment Sensor(s). Model: Bravo [:) Dispenser Containment Sensor(s). Model: (9 Shear Valve(s). ®Shear Valvc(s). 0 Dispenser Containment Float(s) and Chain(s). C3 Dispenser Containment Float(s) and Chain(s). Dj,*pcnwr1D,_DjeSe) 3 Dispenser W: Dispenser Containnient Scrisor(s). Model: Bravo 0 Dispenser Containment Sensor(s). ModcL Shear Valve(s) [I Shear Valve(s). DispeiLwr Containinent Float(s) and Chain(s). 0 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 Nerify that this information is correct and a Plot Plan showing the layout of monitoring equipincnt. For any equipment capable of generating such reports, I have also attached a copy of the report; (check au that apply): IR—System set-up ��_rAlarnn history report Technician Naine Brian Thornton Signature: Certification No.: A31562 License. No.: 724513 A, C-10, HAZ ICC# 6024962 -UT Testing Company Name: Thornton Environmental Construction, Inc. Phone No.: (209) 834-0792 Testing Company Address: PO Box 360833 Milpitas, CA 95036 Date of esting/Servicing: 7-30-2018 Page I of 3 ESH-EFA-TKS-1 8-15666-SM/EM:mw