COMPLIANCE INFO_FILE 12 - Laserfiche WebLink

Home Browse Search

t MONITORING SYSTEM CERTIFICATION 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 of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Lawrence Livermore National Laboratory Site 300 =Bldg.No. 882 Site Address: Corral Hollow Road City: Trac Zip: 95376 Facility Contact Person: Willie Smith Contact Phone No: (925)423-0414 Make/Model of Monitoring System: USD LA-02 Date of Testing/Service: 9-21-2005 B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicatespecific a ui meat inspected/serviced: Tank ID: 882-DIUI DIESEL Tank ID: ❑In-Tank ng Probe. Model: ❑In-Tank Gau 'n Probe. Model: ■Annular Space or Vault Sensor. Model: LALS-1 ❑Annular Space or Vault Sensor. Model: ■Piping Sum /Trench Sensor(s). Model: LALS-1 ❑Piping Sum /Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on ❑Other(specify equipment type and model in Section E on Page 2) e2 Tank ID: Tank ID: ❑hi-Tank Gauging Probe. Model: ❑hi-Tank qatjCpng Probe. Model: ❑Annular Space or Vault Sensor. Model: ❑Annular Space or Vault Sensor. Model: ❑Piping Sum /Trench Sensor(s). Model: ❑Piping Sum /Trench Sensor(s). Model: ❑Fill Sump Sensors). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Tank Overfill/Hi -Level Sensor. Model: ❑Other(specify equipment type and model in Section E on ❑Other(specify equipment type and model in Section E on Pap ,e 2) Page 2 Dispenser ID: NO DISPENSERS Dis enser ID: ❑Dispenser Containment Sensor(s). I Model: ❑Dispenser Containment Sensor(s). I Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Float(s) and Chain(s). ❑Dispenser Containment Float(s) and Chain(s). Dis enser ID: Dis enser ID: ❑Dispenser Containment Sensor(s). I Model: ❑Dispenser Containment Sensor(s). I Model: ❑Shear Valve(s). ❑Shear Valve(s). ❑Dispenser Containment Floats and Chain(s). ❑Dispenser Containment Floats 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): ❑System set-up ❑Alarm history re rt Technician Name: Brian Thornton Signature:--./:5--- Certification i nature:Certification No. 02-0276 License No. CSLB#724513 ICC#5132288-UT TeAmg Company Name: Thornton Environmental Construction, Inc. Phone No. 408 946-1015 Page 1 of 3 03/01