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10/01/2009 20:12 FAX 925 422 2748 WGMG la 008/011 I Q Gv �SYSTEMCE T�,E�T 1.1 For U.se By Alt Ju il.vdictions Within rice Stare of CaltOmia ,Iuthority Cited: Chapter 6.7, !Health and Safely Code; Chapter 16, Division 3, Title 73, California Code of Reguladons Y r7l !1 11 I a .. I, 1a` >7,w� a .o monita—N system cmttml pertel by the technician who pufar<ms the work A copy of this foam must be provided to the tank system owner/operator The owner/r mag submit a copy of this form to the local agency regulating UST system within 30 days of test date. A. General Information Facility Name: Lamence Uvermom National Labordog Site 300 Bldg. No.: $882 Site : CorFal_Hollow Road City: Tracy Zip: 95376 Facility Contact Person: Willie Smut Contact Phone No.: (926) 423.0414 MakmNodel of Monitoring $ : USD Leak Alert LA -02 Daze of Testing/Servicing: 9-21-2009 B. Inventory of Equipment Tested/Certifed boxes a indlew sbecift egabanew Tank aria: 8 1U1 Diesel Tank W. ❑ iw-7'aatc C"eeatt6m Probe. Model: ❑ la -Tank Gauging Probe. Moehel: ® Anxitar Space *.- VmK Sensor. Model: LALS-1 ❑ Annular spm or Vank Sem. MLA& Plpft Sump /'rrcach ' s} Model: LLS -1 13 /Trench s). Memel: ❑ t=ill sump sec>soa(s� Model: 13 Al Sung► smorm C3 Mechanical Lore lralc ❑ Macloaximl Lore Leak Detector. AModek Lire Leak 0doedor. Model: [3E1 Line Leak Deleelor. Model: Tack Ovdrfull / High 1"d . Model: rrc-03 13Tank Overfill / Him -levet Model: Other ( type and model in Saxton E on Page 2} ❑ Other (speedy equipmerA ripe and model is Section E on Page 2). Tank ®: Tank ID: ❑ In -Tank Gmov Probe. Madel: ❑ In:renkc3aupwProbe. Model: ❑ Annular Spam or vault Seem Model: ❑ Annular Space or Vank Sensor. Model: ® Piping Sump / Trench Sens (s). Model: ❑ PVmg Sump / Trench S s� l: ❑ Fill Somp swor% !Model: ❑ Fin sA Model: ❑ eel Tune Leak Doteclor. Model: ❑ Machanical Lina Leak Detector. Modal: ❑ Elecuvoic Line Leak Detector. Model: Line Lrak Delmer. Madel: ❑ Tank Overfill / High -Level Smor. Model: [] Tadt OMM I LeVd SWW. Model: ❑ Ocher (specify type tad otodei is Section E on Pap 2k ❑ Odur (sp&.* aqutramat type and model in Secdon E an Pap 21 Dispenser m: NO DISPENSERS Dispeaser Ur ❑ s). Model: ❑ DLVWLW Containment Sensnr(s). Model: 4 Star Vatve(a). ❑ Sherr Vatve(s). ❑ Dupausir C ! loWs.) and Cl -(s� ❑ DMMW Contammem Flost(s) and Chain(e). Dir r ID r M. ❑ s) ❑ Dispenser co a). Moder ❑ sheff Vatve(s). ❑ Shear Vaive(s). ❑ Dopensfar Commumn Floac(s) and s). ❑ Dispenser'Flom(,) and s). Dispenser M. Dir er ID: ❑ Dispeow CoNainmed Saawr(s� Modal, ® Dispenler ContoWment Sensors). Model: ❑ Shcar Valvc(s}. ❑ $bear Valvc(4 ❑ Dispenser Coulammem Flost(a) and Chains) ❑ EloWs) and Cham(al y tU:MM; 1 U♦1"1 ;,.1 17.1 i'_f.. 1. ,..}1ui�.�� 'TV1 07711111171 i.:i 111 stili ::7l. Iir til. f:,� r;11 ,71 rlL,:l.'i ).�!':1 :I 1`- Y,.("Nk C. Ce Cation - I certify that the equipment identiPted in this doeaineat was inspectodloerviced in accordxuw with the manufacturers' giddellm Attacked to this Certification i:♦ inforssation (e.g afaetarers'checklists) nemsary to verity that this Information is correct and a Piot Plass showing the layout of muniforin equipmezLL For any equipment capable of generatin such reports, t have also attached a copy of the repots; ( s CJS -up ❑ Alarin history report Technician Name Brian Thornton signature: Certification No": A31562 .License. No.: 724513 A. C10, HAZ ICCO 2825 -UT Teaft Company Name: Thornton EnWonmental Construction, Inc. Phone No., () 792 Testing Company : PO Box 360833 Mil ' , CA 95026 Date of T :9-21 2009 Page 1 of 3