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FI LfATE Thornton Environmental Constructs nQ P.G. Box 360833 Milpitas, CA 95036-0833 Phone (408) 946-1015 • (209) 834-0792 9 Fax (209) 834-0795 E Monitoring System Certification OCT o g 2 A. General Information I. ENVIRONMENT HHEALTH Facility Name: Lawrence Livennore National Laboratory Site 300 d o. 879 Site Address: Corral Hollow Road Cite: Tracy Zip: 95376 Facility Contact Person: Willie Smith Contact Phone No: (925) 423-0414 Make/Model of Monitorins; System: Gilbarco EMC Date of Testirrt; / Service: 9-8-2008 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate s cific EgujMient ins ected/semiced: Tank ID: 879-G3U1 UNLEADED II Tank ID: 879-DIU1 DIESEL ■ hi -Tank Gauging Probe. Madel: Mag 1 ■ Armular Space or Vault Sensor. Model: 794390420 ■ Piping Sum / Trench Sensor(s). Model: 794380-205 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Madel: D Tank Overfill / High -Level Sensor. Modet: ❑ Other (specify equipment type and model in Section E on Page i hi -Tani: Gauging Probe. Model: Mag 1 ■ Annular Space or Vault Sensor. Model: 794390420 ■ Piping Sump / Trench Sensor(s). Model: 794380-205 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: 0 Electronic Lune Leak Detector. Model: El Tank Overfill / Hi -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2 Tank ID: Tank ID: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sum / Trench Sensor(s). Model: ❑ Fill SumpSensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2 ❑ hi -Tank Gauging Probe. Model. ❑ Aimular Space or Vault Sensor. Model: ❑ Piping Sum / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Mcxiel: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specify equipment type and model in Section E on Page 2) Dispenser ID: UNLEADED 1-2 Dispenser ID: DIESEL 5 ❑ Dispenser Contaimuent Sensor(s). Model: ❑ Dispenser Contaimnent Sensor(s) Model: ■ Shear Valve(s). ■ Shear Valve(s). ■ Dispenser Containment Float(s) and Chain(s). ■ Dispenser Containment Float(s) and Chain(s). Dispenser ID: UNI,EADED 34 Dis enser ID: ❑ Dispenser Contaimnent Sensor(s). Model: ❑ Dispenser Containment Sensor(s). I Model: ■ Shear Valy s). ❑ Shear Valve(s). ■ Dispenser Containment Float(s) and Cham(s). ❑ 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 cony of the renort- 1rhrrk aU that annlvi- ❑ Svstem set -nn ❑ Alarm hietary renart Technician Name: Brian Thornton Si nature:, --- ,!-- Certification No. A31562 i License No. 724513 ICC No. 5302825 -UT Testing Company Name: Thornton Environmental Construction, Inc. I Phone No. 408 946-1015 Page 1 of 3 03/01