COMPLIANCE INFO_FILE 13 - Laserfiche WebLink

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P MON170RING SYSTEM CERTIFWTION For Use 4y A// Jurisdictions Within the State of California .4uthoritv Cited: Chapter 6 7, Health and LafetE Code; Chaater 16, Division 3, Title 23, California Code o latil This form must be used to document testing and servicing of monitoring equipment. A to certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this USfq 5tank system OWP ;1 owner/operator. The owner/operator must submit a copy of this form to the local agency regulating date. A. General Information SEP 0 3 zUio Facility Name: Lawrence Livermore National Laboratory Site 300 ENS IROIVAMalda.,No.:B882 Site Address: Corral Hollow Road Facility Contact Person: Willie Smith B. Inventory of Equipment Tested/Certified Check the appropriate boxes to Indicate sDccfflc eaulmnent ins ected/serviced: City: Contact Phone No.: (925) 423:MA Date of Testing/Servicing: 8-30-2010 Tank ID: 882-D1 U1 Diesel Tank ID: 0 In -Tank Gauging Probe. Model: 0 In -Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: LALS-1 0 Annular Space or Vault Sensor. Model: 0 Piping Sump / Trench Sensor(s). Model: (.ALS -1 0 Piping Sump / Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model- [I Electrode Line Lp-* Detector. Model: El Tank Overfill / High -Level sensor. Mom: 0 Tank Overfill / High -Level Sensor. Model: n Other (specify equipment type and model in Section E on Page 0 Other (specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: [I In -Tank Gauging Probe. Model: F1 In -Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: El Annular Space or Vault Sensor. Model: 0 Piping Sump J Trench Sensor(s). Model: 0 Piping Sump / Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Fill Sump Setiseqs). Model: 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: [I Tank Overfill / High -Level Sensor. Model: 0 Other (specify equipment type and model in Section E on Page 2). rl Other (specify equipment type and model in Section E on Page 2). Dispenser ID: NO DISPENSERS Dispenser M. D Dispenser Containment Sensor(s) Model: F1 Dispenser Containinent Sensor(s). Model: 0 Shear Valve(s). 0 Shear Valve(s). r-1 Dispenser con tainmerit Float(s) and Chain(s). 0 Dispenser Containment Float(s) and Chain(s) Dispenser ID: Dispenser ID: [I Dispenser Containinent Sensor(s). Model: [I Dispenser Containment Sensor(s). Model: [I Shear Valve(s). [I Shear Valve(s). 0 Dispenser Containment Floats) and Chain(s)- 0 Dispenser Containment Float(s) and Cham(s). Dispenser ID- Dispenser ID: 0 Dispenser Containnient Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). ❑ She- Valve(s). [] Dispenser Containment Float(s) and Chain(s). 0 Dispenser Containment Float(s) 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; (cheek all that apply): F1 System set-up ❑ Alarm history report Technician Name Brian Thornton Signature: ---------- Certification No.: A31562 License. No.: 724513 A, C10, HiFZ 1CC# 5302825 -UT Testing Company Name: Thornton Environmental Construction, Inc. Phone No.: (209) 834-0792 Testing Company Address: PO Box 360833 Milpitas, CA 95036 Date of Testing/Servicing: 8-30-2010 Page 1 of 3