COMPLIANCE INFO_FILE 13 - Laserfiche WebLink

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U MON GSYSTEM CERTIF *kTION For Use By All Jurisdictions Within the State of California -4 uthoritv Cite& Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations Tins form must be used to document testing and servicing of monitoring equipment A to =hfication or report must be ppgpgrgd for each monitoring system control panel by the technician who performs the work- A copy of this til tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating w4st date. �k=z� L A. General Information STP 0 3 4U10 Facility Name: Site Address: Lawrence Livermore National Laboratory Site 300 B879 Corral Hollow Road City: Tracy PERtOMERVI"i6376 Facility Contact Person: Willie Smith Contact Phone No.: (925) 423-0414 Make/Model of Monitoring System: Gilbarco EMC Date of TestingIServicing: 8-30-2010 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to hulicate specitic equipment inspected/serviced: Tank ID: 879-G3UI Unleaded Tank ID: 879-D1 Ul Diesel 0 In -Tank Gauging Probe. Model: I 0 In -Tank Gauging Probe. model: Mag 1 Annular Space or Vault Sensor. Model: 794390420 Annular Space or Vault Sensor. 'Mag Model: 794390420 Piping Sump / Trench Sensor(sk Model: 794380-205 Piping Sump / Trench Sensor(s). Model: 794380-205 El Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: El Mechanical Lire Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor Model: 0 Tank Overfill / High -Level Sensor. Model: ❑ 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 ED: Tank ID: 0 In -Tank Gauging Probe- Model: [I In -Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: F-1 Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: [I Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: F1 Electronic Line Leak Detector. Model: C1 Electronic Line Leak Detector. Model: El Tank Overfill / High -Level Sensor. Model: [I Tank Overfill / High -Level Sensor. Model: [I Other (specify equipment type and model in Section E on Page 2). 0 Other (specify equipment type and model in Section E on Page 2). Dispenser ED: Unleaded 1 Dispenser ID: 0 Dispenser Containment Sensor(s). Model: Bravo n Dispenser Containment Sensor(s). Model: Shear Valve(s). [I Shear Valve(s). Dispenser Containment Float(s) and Chain(s). ❑Dispenser Containment Float(s) and Chaui(s) Dispenser ID: Unleaded 2 Dispenser ID: ❑Dispenser Containment Sensor(s). Model: Bravo El Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). Dispenser Containment Float(s) and Chain(s). ❑Dispenser Containment Fl-t(s) and Chain(s). Dispenser ID: Diesel 3 Dispenser ED: 0 Dispenser Commitment Sensor(s) Model: Bravo 0 Dispenser Containment Sensor(s) Model: 0 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s) and Chain(s). [I 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; (check all that apply): El System set-up El Alarm history report Technician Name -Brian Thomton Signature: Certification No.: A31562 License. No.: 724613 A, CIO, HAZ lCC# 530282 Testing Company Name: Thornton Environmental Construction, Inc. Phone No.: (209) 834-0792 Testing Company Address: PO Box 360833 Milpitas, CA 96036 Date of Testing/Servicing: 8-30-2010_ Page 1 of 3