COMPLIANCE INFO_FILE 13 - Laserfiche WebLink

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MONIAkING SYSTEM CERTIFATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6 7, Health and Safety Code, Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A Leparate certification or LeM must be pictured for each monitoring system control M1 by the technician who performs the work- A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Lawrence Livermore National Laboratory Site 300 Bldg.No.:B882 Site Address: Corral Hollow Road City: Tracy Zip: 95376 Facility Contact Person: Willie Smith Contact Phone No.: (925) 423-0414 Make/Model of Monitoring System: USD Leak Alert LA-02 Date of Testing/Servicing: 8-08-2012 B. Inventory of Equipment Test ed/Certirted Ch-k the"ATE—te hies to_Wd-ate!p!!!L-MM!T!lms se Tank ID: 882-D7 Ui Diesel Tank ID: *in-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: *Annular Space or Vault Sensor. Model: LALS-1 0 Annular Space or Vault Sensor. Model: 0 Piping Sump/Trench Sensor(s)- Model: LALS-1 [I Piping Sump/T-nch Scnsor(sj Model: [I Fill Sump Sensor(s). Model: [I Fill Sump S--(s)- Model: F1 Mechanical Line Leak Detector. Model: [I Mechanical Line Leak Detector. Model: 0 Electronic line Leak Detector. Model: 0 Electronic Line Lzak Detector. Model- 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: [I Other(specify equipment type and model in Section Eon Page 2) 0 Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: ❑In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe Model: ❑Annular Space or Vault Sensor. Model: n Annular Space or Vault Sensor. Model: •Piping Sump I Trench Sens-s). Model: 0 Piping Sump I Trench Sensor(s). Model: •Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Mechanical Lane Leak Detector Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: 0 Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-level Sensor Model: El Other(specify equipment type and model in Section E on Page 2). n Other(specify equipment type and model in Section E on Page 2). Dispenser W. NO DISPENSERS Dispenser ID: 0 Dispenser Containment Sensor(s). Model: 171 Dispenser Oxnaimuent Sensor(s). Model: El Shear Valve(s). 0 Shear Valve(s). [I Dispenser Containment Floats)and Cham(s) n Dispenser Centamment Float(s)and Cham(s) Dispenser]ED: Dispenser ID: [I Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: F-1 Shear Valve(s). []Shear Valve(s). [I Dispenser Containment Floats)and Chain(s). 0 Dispenser Contair—ent Float(s)and Chain(s). Dispenser ID: Dispenser ID: D Dispenser Containment Sensor(s). Model: [I Dispenser Containment Sensor(s). Model: ❑Shear Valve(s). 0 Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(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 copy of the report;(check all that apply): ❑System set-up Q Alarm history report Technician Name Brian Thornton Signature: Certification No.: A31562 License.No.: 724513 A, C-10, HAZ lCC#5024962-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: 8-08-2012 Page 1 of 3