COMPLIANCE INFO_FILE 14 - Laserfiche WebLink

Home Browse Search

MONI SYSTEM CERTIF*Tl 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 6fAe§Whti This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be proared for each monitoring system control panel by the technician who performs the work. A copy of this form must _ft�,prpv idcd� owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systemsN p pof, to*, d4 "r 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: Diane Griffin Contact Phone No.: (925) 423-1547 Make/Model of Monitoring System: USD Leak Alert LA -02 Date of Testing/Servicing: 8-01-2017 B. Inventory of Equipment Tested/Certified Check the appropiriate boxes to indicate s cific equipment ins pEE"serviced: Tank ID: 882-TFUDOI Diesel Tank ID: ❑ In -Tank Gauging Probe. Model: El In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: LALS-1 E:1 Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: LALS-1 El Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: [I Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: n Tank Overfill / High -Level Sensor. Model: [I Tank Overfill / High -Level Sensor. Model: [I Other (specify equipment type and model in Section E on Page 2). n Other (specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: C:1 In -Tank Gauging Probe. Model: El In -Tank Gauging Probe. Model: F-1 Annular Space or Vault Sensor. Model: El Annular Space or Vault Sensor. Model: F-1 Piping Sump / Trench Sensor(s). Model: ❑ Piping Sump / Trench Sensor(s). Model: El Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: n Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: El Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor, Model: 0 Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2). El Other (specify equipment type and model in Section E on Page 2). Dispenser ID: NO DISPENSERS Dispenser ID: 0 Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: El Shear Valve(s). ❑ Shear Valve(s). El Dispenser Containment Float(s) and Chain(s). F1 Dispenser Containment Float(s) and Chain(s). Dispenser 111 Dispenser ID: [I Dispenser Containment Sensor(s). Model: F1 Dispenser Containment Sensor(s). Model: El Shear Valve(s). El Shear Valve(s). El Dispenser Containment Float(s) and Chain(s). El Dispenser Containment Float(s) and Chain(s). Dispenser ID: Dispenser 111): El Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: [I Shear Valve(s). El Shear Valve(s). [I 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): ystem set-up arm history report Technician Name Brian Thornton Signature: Certification No.: 8-0472 License. No.: 724513A,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 Testing/Servicing: 8-01-2017 Page 1 of 3