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b <br /> UNDERGROUND STORAGE TANK aIIG 1 zO�O <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 cn jf" j1M1o0*E L I H <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 Mondodr1q.,Sy�sl;�rr�CLe ijcation <br /> �usiness Name (Same as Facili N the or A- ing usiness As) Building# LU (J <br /> awrence Livermore �Ja IonaP�a�ora'�ory 882 <br /> B1 i6V UQde <br /> orral Hollow Road TVacy J�M76 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> Thornton Environmental Construction, Inc. 209-834-0792 <br /> Mailin Address <br /> P.O.gBox 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 /> CS LB A, C-10, HAZ#724513 5024962-UT 02-27-2022 <br /> Monitorin S stem Trainin and Certifications List all a livable certifications. Ex iration Date <br /> e - o e e - - <br /> Pneumercator 910208 03-23-202T_ <br /> VMI s #2010 VMI 890 lestUnit -09-202-1— <br /> Ill. RESULTS OF TESTING/SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br /> ElMonitorin System Set-up ®Alarm Histo Report <br /> Y N NA <br /> Was any monitoring equipment replaced? El ® El <br /> "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? 1:1(If"Yes,"describe what was found in section IV below.) 9 El <br /> Is all monitoring equipment operational per manufacturers specifications? ® El 1:1(lf"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 /> This system does not have a printer, a copy of the Alarm Log is attached. <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 ver?ty 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=kiertification,ICC=International Code Council,Y=Yes,N=No,NA=Not Applicable <br /> UN-107 www.unidocs.org 116-Rev.10101/18 <br />