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11 MONITORING SYSTEM CERTIFICATION F'or Use By All Jurisdictions Within the State of Ca "or / fi nf �,yIRONMENTAL HEALTH Authorttv Cited.- Chapter 6.7, Health and Safety Code: Chapter 16, Division 3, Title 23 rni b(00ft"t"T '111is foral 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 USTs} stems within 30 days of test date. 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: Phyllis Cox Contact Phone No.: (926) 423-9658 Make/Model of Monitoring System USD Leak Alert LA -02 Date of Testing/Servicing: 7-30-2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate sMinc equipment in=dedlservtced: Tank : 882-TFUDOI Diesel Tank W, C3 Itit:t*ank, Gauging Probe. Model: 0 In -Tank Gauging Probe Moa!4 0 Annular Space or Vault Sensor. Model: LALS-1 0 Annular Space or Vault Sensor Model, (0 Piping Sump frenchhSensor(s) Model: LALS-1 0 Piping Sump Trench Sensor(s), Model, 0 Fill Stamp Sensor(s) Model: [I Fill Sump Sensor(s). Model, El 'Mechanical Late Leak Detector, Model: 0 Mechanical Line Leak Detector. Model; 0 Electronic Line Leak Defector. Model- 0 Electronic Line Leak Detector, Model: El Tank Overfill Iligh-Level Sensor Model: 0 Tank Overfill r Fligh-Levet Sensor. Model: [j Other (specify equipment type and model in Section E on Page 2). 0 Other (specify equipment type and model in Section E on Page 2). Tank LD: Tank ID: 0 In -Tank Gauging Probe. Model: 0 In -Tank Gauging Probe, Model: 0 Annular Space or Vault Sensor Model: 0 Annular Space or Vault Sensor. Model: 0 Piping Sump rrtrich Sensor(s) Model: 0 Piping Sump Trench Scrasor(s). Model: 0 Fill Stamp Sensor(s). Madel: 0 Fill Sump Senson(s), Model: 0 Mechanical Line Ieak Detector Model: 0 Mechanical Line Leak Detector. Model: au 0 Electronic lectrnc Line Leak Deteutor. Model: 0 Electronic Line Leak Delft -tor. Model: OTankOverfill High -Level Sensor. Model: El Tank Overfill Nigh -Level Sensor, Model: 0 011war (specify equipment type and model in Section E on Page 2). El Other (specify equipment type and model in Section F on Page 2), Dispenser tD: NO DISPENSERS Dispenser ID: El Dispenser Containnient Sensor(s). Model: 0 Dispenser Conlairunent Seimr(s). Model: El Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s) and Chum(s). 13 Dispenser Comairunent Float(s) and Chain(s). Dispenser ID: Dispenser ID: F-1 Dispenser Containment Serastar(s). Model: 0 Dispenser Containment Sensor(s). Model: C1 Shear Valve(s). 171 Shear Valve(s). 0 Dispenser Containment Floats) and Chain(s). El Dispenser Containment Floats) and Chain(s). DispenserID: Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s) El Shear Valve(s). [I Disperser Containment Float(s) and Chain(s). 0 Dispenser Containment Floats) and Chain(s). *If the facility contains more tanks or dispensers, copy this forni. include information for every to nk 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 equient. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): 5 System set-up >9,Alarm history report Technician NameBrian Thornton Signature:.. Certification No.: 8-0472 License. No.: 724513 A, C-10, HAZ 1CC# 5024962 -UT Testing Company Name: Thornton Environmental Construction, Inc. Phone No.: (209) 8340792 Testing Company Address: PO Box 360833 Milpitas, CA 95036 Date of Testing/Sendcin& _7.30-2018 ---- Page I of 3 ES H-EFA-TKS-18-15666-SM/EM:mw