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10/01/2009 20:10 FAX 925 422 2748 Me 1a003/011 NIT RING SYSTEM CERTIF14RTION For Uve By A fi Juns&ctivns rithin the State of California _lurhorlty CitedChapter 6.7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used W docutnuit testing and servicing of moultoring equipment A KM& ccttihcabon or =2d must be WgI94 & each MojUIEU 0= control lanad by the technician who peffam the work. A copy of this form most be pwvided to the tank system owner/operator. The owner/operator must submit a copy of iMs form to dke local agency regulating UST mftm within 30 days of test date. A. General Information Facility Name: Lawmnee Livermore National Laborer Sipa 300 Bldg. No.: B372 Site A I Hollow Road City: Tracy Zip: 95376 Facility Contest ' Willis Smit Contact Phone No.: 925 423-"l 4 Makemodal of monitoring System Gilbamo EMG Date of Testing/Servicing: 9.21-2009 B. Inventory of Equipment 'I'ested/Ce ' ed Tank ID: 879-G3U1 Unleaded Tank ID: 8 1 U1 Diesel ® Ut-Tait Gxogog Probe. Madel: ft 9 ® in -Tank Gwos Probc. Model: 1 ® Amader Spay or Vwk Sem Model: 794=40 Aneuint SPwx ur Vath Somw Model: IN Piping Sump/ Tmwh e). Model: ® Piping Sunw / TwocL ej Model: 7 ❑ Fill S=w ' s), Modd: ❑ Fill Sump a} Model: ❑ Mimbanicil Lau Irak Daector. Model: ❑ Medmikel Line Leak DdaAor. Model: ❑ sectrodo Lino Lack Detector. Model: ❑ El c Litre Leak Dmaw. Model: ❑ Tank Ovafill / 14igh-Loud ❑ Tank Omfill / High-level Smor. Modal: ❑ Odier (may type and model m Seafan E an Page 2N ❑ Ott (wec ify mapoent type and modiel mi -Section E an Page 2A Tauk IQ Tank ID' ❑ WTwkonsingftow, Model: ❑ In -Tads Gloag" Probe. Model: ❑ Annular Spam or Vault Sensw Model: ❑ Anmibw Space or Vauh SONEW Modet: ❑ PTzg Sup / Trench a). Madel: ❑ Piping Sump / T sA Madel: ❑ Fill sj Model: ❑ Fill %). Model: ❑ Mechwical Linc Leak 17doctor. Model: ❑ Mochuzicd Line Leak Detector. !Model: ❑ Elccnwk Lica Lsak Model: ❑ Electrotdo Lim Irak Deuxtor. Model: ❑ Tank Overfill / High -Level Sewer. Model: Q Tank Ovaffl / Higb-Love( Smor, MWd: ❑ Other (spec* ewwozed type and model m E an Pogo 2). ❑ Odw ( type andmodel in Sediott E on Page 2j. Dispenser ID: Un ed 9 Dispenser ID: ❑Dupmw Cammumcd Semor(a). Model- ❑ %). MOM, ®Mmr vahre(s} ❑ Sheer valve(%} ® s) e� ❑ s) end Chain(v)- Dispenser in Unleaded 2 Dispamw W. ❑ s}. Model: ❑ Dispeow Canwittraft S %} Model: Shrar Yalvo(e� ® show vaivo(4 ® Dapnow CmU Ftoai(s) and dein(%} ❑ Float(s) and Chi a(s� Dispenser m, Diesel 3 Dispestser ID; ❑ ' S %) l: ❑ 9} Model: ® Shear valve(%). ❑ Sbw Valve(s). ® Floats) sod C!19m(8). ❑ Dqxaw Coam s) and a-n(s) ,,If the facility contains more tanks or 49nnset7s. copy toys form Include b1brination for every tank and dispenser at the facility. C. CCrWiCatiOn - I certify that the equipment Identified In this document was ins seMced is accordance with the mamiflictursiV guidelines, Attached to this Certification is Warmadon (e g. manubdureW clleddists) necessary to yeft dw this infbination Is cornet and a Plot Plan dwwIng the layout of monitoring equipmeaLFor any equipment cqmw of gesteralft such reports, I bove also aftched a copy of the report; (che& ash duo mppk).- ❑ Sset-up ❑ Alarm beatory mpart Technician Name Brian Ti]omRon S rc: "9�/ Certification, No.: A31562 License. No.: 724513 A, CIO. HAZ I T Testing Company Name: Thomt?otn Environmefflal Constiuction. Inc. Phone No.: (20!1834-0792 Tcstiug Compoy Address. Pa Box 3NM Mile-!", CA ON36 Date aEf T ting: 921-2009 Pap 1 of 3