Laserfiche WebLink
Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report Form <br />TYPE OF ACTION ❑ Installation ❑ Repair ❑x 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10154767 <br />Inspection Date <br />5/20/2024 <br />Facility Name <br />Lawrence Livermore National Laboratory Bldg. 879 <br />Facility Address <br />15999 W. Corral Hollow Road <br />City <br />Tracy <br />ZIP Code <br />95376 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />Thornton Environmental Construction, Inc. <br />Phone <br />(209) 834-0792 <br />Mailing Address <br />PO Box 360833 Milpitas, CA 95036-0833 <br />Service Technician Performing Inspection <br />Brian Thornton <br />Contractor/Tank Tester License Number <br />CSLB #724513 A, C-10, HAZ <br />ICC Number <br />5024962-U 1 <br />Expiration Date <br />12/4/2024 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />OPW #104777 <br />1/10/2026 <br />EMCO Wheaton #3253 <br />8/31/2025 <br />FFS EVR Phase 1 #1029543709 <br />7/6/2025 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used Components Inspected <br />OPW IOM OPW Overfill Prevention Valve <br />PEI 1200 OPW Overfill Prevention Valve <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br />I hereby certify that the OPE was inspected in accordance with California Code of <br />Regulations, title 23, division 3, chapter 16, section 2637.2; that required supporting <br />documentation is attached, and all information contained herein is accurate. I understand <br />that test procedures shall be made available upon request by the governing authority. <br />Service Technician Signature <br />r--/ <br />Date <br />5/20/2024 <br />Total # of Pages <br />10 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment <br />UN -109 www.unidocs.org Rev. 10/01/20 Page 1 of 2 <br />