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MONIWING SYSTEM CERTIF*kTION For Use BvA//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 20arate certification or report must be pLe ..each paredor f monitoring system control ppel 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 Live are National Laboratory Site 300 Bldg.No.: 8879 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 Clie&the mrmj!!Le boxes to intReate sM!Llc ,t!!M-tedlserviced: Tank ID: 879-G3UI Unleaded Tank iD: 879-DI Ul Diesel 0 in-Tank Ganging Probe. model: MN 1 10 in-Tank Gauging Probe. Model: Mag I 0 Annular Space or Vault Sensor. Model: 794390-420 0 Annular Space or Vault Sensor Model: 794390-420 0 Piping Sump/Trench Sensor(s). Model: 794380-206 0 Piping SUMP/Trench Sensor(s)- Model: 794380-205 [I Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model- El Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: El El—tionic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model- []Tank Overfill/High-Level Sensor. Model: rl Tank Overfill/High-Level Sensor. Model: 0 Other(specify etluipment 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: ❑In-Tank Gauging Probe. Model: 0 In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sewer. Model: 0 Piping Sump/Trench Sensor(s). Model: 0 Piping Sump/Trench Sensor(s). Model: [I Fill Sump Sensor(s). Model: [I Fill Sump Sensor(s). Model: [I Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: 0 Electronic Lim Leak Detector. Model: 0 El Line Leak Detector. Model: [I Tank Overfill/High-Level Sensor. Model: [I Tank Overfill/High-Level Sensor Model: [I Other(specify equipment type and model in Section E on Page 2). [I Other(specify equipment type and model in Section E on Page 2) Dispenser ID: Unleaded I Dispenser TD: El Dispenser Containment Sensor(s). Model: -Bravo 0 Dispenser Containment Scnsor(s� Model: Shear Valve(s). 0 Shear Valve(s). Dispenser Containment Float(s)and Cham(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 S—or(s) Model: 0 Shear Valve(s). 0 Shear Valve(s). 0 Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Floats)and Chain(s)_ Dispenser ID: Diesel 3 Dispenser ED: 0 Dispenser Containment Sensor(s). Model: Bravo 0 Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). 0 Shear Valve(s). 0 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 iaiik 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 aU that apply): R_Systern set-up �MAlarm history report Technician Name -Brian Thornton Signature: Z'f Certification No.: A31662 License.No.7724513 A,C-10, HAZ ICC#6024962-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