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MONI SYSTEM CERTIFI&TION For Use By All Jurisdictions Within the State of California Authority Cited.- Chapter 67, 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 separate certification or report must be prepared for each monitoring 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/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: 96376 Facility Contact Person: Diane Griffin Contact Phone No.: (925) 423-1547 Make/Model of Monitoring System: Gilbarco EMC Date of TestinglServicing: 8-1-2017 B. Inventory of Equipment Tested/Certified Check theappropriate boxes to indicate s cific equipment ins cted/serviced: Tank ID: 879-TFUG01 Unleaded Tank w: 879-TFUD0I Diesel 0 in -Tank Gauging Probe. Model: MN 1 ED in -Tank Gauging Probe. Model: Mag 1 0 Annular Space or Vault Sensor. Model: 794390420 Annular Space or Vault Sensor. Model: 794390420 0 Piping Sump / Trench Sensor(s). Model: 794380-205 Piping Sump / Trench Sensor(s). Model: 794380-205 El Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 99LD-2000 D Mechanical Line Leak Detector. Model: El Electronic Line Leak Detector. Model: 0 Electronic Line Leak Detector. Model: El Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: 0 Other (specify equipment type and model in Section E on Page 2). ❑ Other (specify equipment type and model in Section E on Page 2). Tank ID: Tank ID: [I In -Tank Gauging Probe. Model: El In -Tank Gauging Probe. Model: E) Annular Space or Vault Sensor. Model: El Annular Space or Vault Sensor. Model: C3 Piping Sump / Trench Sensor(s). Model: M Piping Sump / Trench Sensor(s). Model: El Fill Sump Sensor(s). Model: n Fill Sump Sensor(s). Model: 0 Mechanical Line Leak Detector. Model: 0 Mechanical Line Leak Detector. Model: n Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: [3 Tank Overfill / High -Level Sensor. Model: [I 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 ED: Unleaded I Dispenser ED: El Dispenser Containment Sensor(s). Model: Bravo El Dispenser Containment Sensor(s). eh ED Shear Valve(s). [I Shear Valve(s). ED Dispenser Containment Float(s) and Chain(s). F1 Dispenser Containment Float(s) and Chain(s). Dispenser ID: _ Unleaded 2 Dispenser ID: El Dispenser Containment Sensor(s). Model: Bravo [I Dispenser Containment Sensor(s). Model: 0 Shear Valve(s). Dispenser Containment Float(s) and Chain(s). El Shear Valve(s). [:1 Dispenser Containment Float(s) and Chain(s). Dispenser ED: Diesel 3 Dispenser ID: F1 Dispenser Containment Sensor(s). Model: Bravo [I Dispenser Containment Sensor(s). Model: Shear Valve(s). [I Shear Valve(s). Dispenser Containment Float(s) and Chain(s). [3 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 equim nt. For any equipmenj capable of generating such reports, I have also attached a copy of the report; (check all that apply): Ez"System set-up ;�gj_uarrn history report Technician Name Brian Thornton Signature: . 7�7 — Certification No.: A31662 License. No.: 724513 A, C-10, HAZ 1CC# 5024962 -UT Testing Company Name: Thomton Environmental Construction, Inc. — Phone No.: (209) 834-0792 Testing Company Address: PO Box 360833 Milpitas, CA 95036 Date of Testing/Servicing: 8-01-2017 Page 1 of 3