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A MONIAkUNG SYSTEM CERTIFISkTION 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 ofRe lations This form must be used to document testing and servicing of monitoring equipment. A§parate certification or mow must A AP W-VED momigM system control panel by the technician who perform 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"Vltel 7 2 0 11 A. General Information ENVIR . ENTAL HEALTH Facility Name: Lawrence Livermore National Lao mtoiy Site 300 Bldg.No.: CES Site Address: Corral Hollow Road City: Tracy Zip: 96376 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 the!! ge9 toimlicate!pecfflc E9SVM!!Lt ho se Tank ED: 882-DI U1 Diesel Tank ID: *In-Tank Gauging Probe. Model: El in-Tank Gauging Probe. Model: *Annular Space or Vault Sensor. Model: LALS-1 []Annular Space or Vault Sensor. Model: *Piping Sump/Trench Sensor(s). Model: LALS-11 El Pip*sump/Trench sensor(s). Model: [I Fill Sump Semor(s). Model: 0 Fill Sump Sensor(s)- Model: 0 Mechanical Lim Leak Detector. Model: 0 Mechanical Lim Leak Detector. Model: rl Electronic Lim Leak Detector. mom: 0 Electronic Line Leak Detector. Model: [71 Tank Overfill/High-Level Sensor. Model: [I Tank Overfill/High-Level Sensor. Model: [I Other(specify equipment type and model in Seaton E on Page 2). n Other(specify equipment type and model in Section E on Page 2). Tank IID: Tank 11D-. ❑In-Tank Gauging Probe. Moll: 0 In-Tank Gauging Probe. Model: ❑Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: Piping Sump/Trench Sensor(s). Model: 0 Piping Sump/Trench Sensor(s)- Model: ❑Fill Sump Sensor(s). Model: 0 Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector Model: 0 Mechanical Line Leak Detecton Model: 0 Electronic Lim Leak Detector. Model: [I Electronic Line Leak Detector. Model. El Tank Overfill/Higb-Level Sensor. Model: []Tank Overfill/High-Level Sensor. Model: El Other(specify equipment type and model in Section E on Page 2). 0 Other(specify equipment type and model in Seaton E on Page 2). Dispenser ID: NO DISPENSERS Dispenser ID: •Dispenser Cmtainmerd Sensor(s). Model: 0 DLTenw Containment Smsor(s). Model: •Shear Valve(s). 0 Shear Valve(s)- •Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Floags)and Chain(s), Dispenser ED: Dispenser ID: ❑Dispenser Containment Sensor(s) Model: [I Dispenser Containment Sensor(s). Model: • Shear Valve(s). 0 Shear valve(s). •Dispenser Containment Float(.)and Chain(s) [I Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: •Dispenser Containment Sensor(s). Model: 0 Dispenser Containment Satsor(s), Model: •Shear Valve(s). 0 Shear Valve(s). [I Dispenser Containnient Float(s)and Chain(s). 0 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;(ckeck aU the apply): El System set-up F1 Alarm history report Technician Name Brian Thornton Signature: Certification No.: A31562 License.No.: -124513 A, C-10, HAZ ICC#5024962-UT Testing Company Name: Tho on Environmental Construction, Inc. Phone No.:(209) 834-0792 Testing Company Address:PO Box 360833 Milpitas,CA 95036 Date of Testing/Servicing: 8-02-2011 Page 1 of 3