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MONITSMG SYSTEM CERTINOWTION 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 2parate certification or report must be prepared for each monitorim system control pariel 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: 8-02-2011 B. Inventory of Equipment Tested/Certified Check a.21mepte boxes to ta&a j!g& Tank ID: 882-D1 U1 Diesel Tank ID: El In-Tank Gauging Probe. Model: 0 In Tank Gauging Probe Model: Annular Space or Vault Sensor. Model: LALS4 n Amular Space or Vault Sensor. Model: Piping Sump/Trench Se-or(s). Model: LALS-1 0 Piping Sump/Trench Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: n Mechanical Line Leak Detector- Model: r—*1 Electronic I=Leak Detector. Model: 0 Electronic Line Leak Detector. Model: rl Tank Overfill/High-Level Sensor. Model: 0 Tank Overfill/High-Level Sensor. Model: n Other(spec*equipment type and model in Section E on Page 2) []Other(specify equipment type and model in Section E on Page 2). Tank]ED: Tank ID: 0 In-Tank Gauging Probe Model: 0 In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: E]Annular Space or Vault Sensor. Model: ❑Piping Sump/Trench Sensor(s). Model: n Piping Sump/Trench Sensor(s) Model: ❑Fill Sump Sensor(s). Model: [I Fill Sump Sensor(s)- Model: ❑Mechanical Line Leak Detector. Model: [I Mechanical Line Leak Detector. Model: ❑Electronic Line Leak Detector. Model: [I 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}. [I Other(specify equipment 13W and model in Section E on Page 2). Dispenser ID: NO DISPENSERS Dispenser ID: n Dispenser Containment Sensor(s). Model: 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: Dispenser 11D: F-1 Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: n Shear Valve(s). []Shear Valve(s). 0 Dispenser Containment Floats)and Chain(s)- 0 Dispenser Containment Ftoat(s)and Chain(s). Dispenser ED: Dispenser ED: [I Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Sensor(s). Model: El Shear Valve(s). [I Shear Valve(s} [I Dispenser Containment Fl s)and Chain(s� [I Dispenser Contak-ent FI 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;(ckeck all tkat apply): El System set-up El Alarm history report Technician Name Brian Thornton Signature: Certification No.: A31662 Lice nse.No.: 724513A, C40, HAZ IC 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