COMPLIANCE INFO_FILE 13 - Laserfiche WebLink

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MONITWING SYSTEM CERTIFIATION 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 rnmtmng equipment A se -f separate certification or report must be prepared or each monitoring system control pgael 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.: B879 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: Gilbarco EMC Date of Testing/Servicing: 8-08-2012 B. Inventory of Equipment Tested/Certified Check the!pjT!pru :ite boxes to imlicate ng!!ME se Tank ID: 879-G3U1 Unleaded Tank ID: 87"1 Ui Diesel 0 in-Tank Gauging Probe. Model: Mag 1 0 In-Tank Gauging Probe. Model: MN I JZ Annular Space or Vault Sensor. Model: 794390420 0 Annular Space or Vault Sensor. Model: 794390420 0 Piping Sump/Trench Scnsor(s)_ Model: 794380-205 0 Piping Sump/Trench Sensor(s) Model: 794380-205 [I Fill Sump Sensor(s). Model: [I Fill Sump Sensor(s). Model: ED Mechanical Line Leak Detector. Model: LD-2000 0 Mechanical Line Leak Detector. Model: F1 Electronic Line Leak Detector. Model: 0 Electronic Line Leak DeteoM Model: • Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-level Sensor. Model: — •Other(spm*equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Section E on Page 2). Tank ED: Tank]D- El In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe Model: E-1 Annular Space or Vault Sensor. Model: [I Annular Space or Vault Sensor. Model: ❑Piping Sump/Trench Sensor(s). Model: 0 Piping Sump I Trench Sensor(s). Model: Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: f-1 Mechanical Line Leak Detector. Model: El Mechanical Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: F1 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 2) F1 Other(specify equipment type and model in Section E on Page 2). Dispenser ID-. Unleaded I Dispenser ID: [I Dispenser Containment Sensor(s). Model: Bravo 0 Dispenser Containment Sensor(s) Model: JZ Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s)and Cham(s) [I Dig—Contaimucut Floats)and Chain(s). Dispenser ID: Unleaded 2 Dispenser ID: 0 Dispenser Containment Sensor(s) Model: Bravo 0 Dispenser Contamment Sensor(s) Model: 0 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: Diesel 3 Dispenser ID: ❑Dispenser Containment Sew"(s). Model: Bravo 0 Dispenser Containment Sewor(s). Model: Shear Valve(s). 0 Shear Valve(s). Dispenser Contiinnient Float(s)and Cham(s). 0 Dispenser Containment Float(s)and Cha-(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(eg.manufacturers' checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipj4ent. For any equipt capable of generating such reports,I have also attached a copy of the report;(check all that apply): L&System set-up R=m history report 'Technician NameBrian Thornton Signature: Cerfification No.: A31562 License. No.:-724513 A, C-10, HAZ 1CC#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