COMPLIANCE INFO_FILE 13 - Laserfiche WebLink

Home Browse Search

MONIT9ING SYSTEM CERTIF140TION For Use By All Jurisdictions Within the State of California Authoritv 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 to certification or pL o Le rt must be e _p_ _ -Lwed for each mgwicirmg system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/ for 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.: (926) 423-0414 Make/Model of Monitoring System: Gilbarco EMC Date of Testing/Servicing: 8-02-2011 B. Inventory of Equipment Tested/Certified Check the Wn2q!Lc boxes to imlicate VES!Lwof serviced: Tank 11): 879-G3UI Unleaded Tank ID: 879-131 U1 Diesel 0 In-Tank Gauging Probe. Model: Mag 1 0 In-Tank Gauging Probe. Model: MN I Annular Space or Vault Sensor Model: 794390420 Annular Space or Vault Sensor. Model: 794390420 Piping Sump/Trench Sensor(s): Model: 794380-206 Piping Sump/Trench Sensor(s). Model: 794380-205 ❑Fill Sump Sensor(s). Model: ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector Model: 0 Mechanical Line Leak Detector- Model: 01 Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: •Tank Overfill/High-Level Sensor. Model: [I Tank Overfill/High-Level Sensor. Model: •Other(spee equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank ID, rl In-Tank Gauging Probe. Model: 0 hi-Tank Gauging Probe. Model: 0 Aimular Space or Vault Sew". Model: 0 Annular Space or Vault Sensor Model: r-1_i - U Piping Sump/Trench Sensor(s). Model: [I Piping Sump/Trench Sensor(s). Model: Fl Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s)_ Model: 0 Mechanical Line Leak Detector. Model: 0 Mechanical Une Leak Detector. Model: 0 Electronic Line 1p—*Detector. Model: [I Electronic Line Leak Detector. mom: n Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/ffigb-Level Sensor. Model: El Other(spec*equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Section E on Page 2) Dispenser ID: Unleaded I Dispenser ID: 0 Dispenser Containment Sensm(s). Model: Bravo 0 Dispenser Containment 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: Unleaded 2 Dispenser ED: 0 Dispenser Containment Sensor(s) Model: -Bravo 0 Dispenser Containment Sensor(s) Model: 0 Shear Valve(s). [I Shear Valve(s). 0 Dispenser Containment Float(s)and ChauKs)- []Dispenser Containment Floats)and Chain(s). Dispenser ID. Diesel 3 114spenser IOD:. El Dispenser Containment Sensor(s) Model: Bravo 0 DispenserContainment Sensoqs� Model- 0 Shear Valve(s). 0 She-Valve(s); 0 Dispenser Containment Float(s)and Chain(s) ❑Dispenser Containment Float(s)and Chain(s)_ *If the facility contains more links 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): ygtem set-up Nwarm history report Technician Name Brian Thornton Signature: Certification No.: A31562 License.No.: 24513 A, C40, HAZ lCC#5024962-UT Testing Company Name: Thornton Environmental Construction, Inc. Phone No.:(209) 834-0792 Testing Company Address:PO Box 360833 Milpitas, CA 96036 Date of Testing/Servicing: 8-02-2011 Page 1 of 3