Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 6) <br /> This form must be used to document testing and servicing of underground storage tank(UST)monitoring equipment. A copy <br /> of this form must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local <br /> agency regulating the USTs within 30 days of the date of the monitoring system certification. <br /> I. FACILITY INFORMATION <br /> CERS ID 10154767 Date of Monitoring_ IA1_�C�e�trtion <br /> Business Name($ame as Fadli N me or A- oin usiness As) Building# LULU <br /> awrence Livermore Kaf lonaPEla�or�a�ory 879 <br /> 1`9i5n'V'V'_'°'U0o ral Hollow Road �'I�acy �m6 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Comany Performing the Certification Phone# <br /> Thornton Environmental Construction, Inc. 209-834-0792 <br /> Mailin Address <br /> P.O.9ox 360833 Milpitas, CA 95036-0833 <br /> Name of UST Service Technician Performing the Certification(Print as shown on the ICC Certification) <br /> Brian Thornton <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> CSLB A, C-10, HAZ#724513 5024962-UT 02-27-2022 <br /> Monitorin S stem Trainin and Certifications Ust all applicable certifications. Ex iration Date <br /> ee - - Uzi <br /> Pneumercator - - <br /> VMl s #2010 VIVII 890 lest Unit -09-202T— <br /> III. RESULTS OF TESTING I SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> Monitoring System Set-up Alarm History Report <br /> Was any monitoring equipment replaced? <br /> (If"Yes,'identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) <br /> Was damage, debris, or liquid found inside any secondary containment systems? 99 <br /> (If"Yes,"describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturers specifications? ® El 0 <br /> (If"No,"describe why in section IV below.) <br /> IV. COMMENTS <br /> If directed to use this section, describe how and when the issues were or will be corrected. <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of <br /> Regulations,Title 23, Division 3,Chapter 16,Section 2638 and all information contained herein is true and accurate. Attached to <br /> this certification is information (e.g., manufacturers'checklists, monitoring system set-up,alarm history report,etc.)necessary <br /> to verify that this information and the site plan showing the layout of UST system is complete and accurate. <br /> UST Service Technician Signature <br /> CERS=California Environmental Reporting System,ID=Identification,ICC=Ir6emationel Code Council,Y=Yes,N=No,NA=Not Applicable <br /> UN-107 www.unidocs.org 1/6-Rev.10101/18 <br />