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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION 17 Installation Ej Repair 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10154767 07-28-2022 <br /> Facility Name <br /> Lawrence Livermore National Laboratory Tanks 879-TFUG01 & 879-TFUD01 <br /> Facility Address City ZIP Code <br /> 15999 W. Corral Hollow Road Bldg. 879 Tracy 95376 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Thornton Environmental Construction, Inc. 209-834-0792 <br /> Mailing Address <br /> P.O. Box 360833 Milpitas, CA 95036-0833 <br /> Service Technician Performing Test <br /> Brian Thornton <br /> Contractor/Tank Tester License Number <br /> CSLB #724513 A, C-10, HAZ <br /> ICC Number ICC Expiration Date <br /> 5024962-UT 2-23-2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder-Root Level 4 #A31562 04-15-2023 <br /> Pneumercator #10208 11-17-2022 <br /> Ronan #7690402 11-12-2022 <br /> VMI MLD's #2010 VMI 890 Test Unit #2009 01-03-2023 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that the monitoring system is operational in accordance with California Code <br /> of Regulations, title 23, division 3, chapter 16, section 2638; that required supporting <br /> documentation is attached, and all information contained herein is accurate. <br /> Service Technician Signature Date Total # of Pages <br /> 07-28-2022 10 <br /> CERS = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br /> ICC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable, SW = Single- <br /> Walled, UDC = Under-Dispenser Containment, UST = Underground Storage Tank, <br /> VPH = Vacuum/Pressure/Hydrostatic <br /> Page 1 of 6 <br />