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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page 1 of 61 <br /> Ffonnst be used to document testingand servicing of underground storage tank (UST) monitoring equipment A copy <br /> ust be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local <br /> tin the USTs within 30 days of the date of the monitoring system certification. <br /> 1. FACILITY INFORMATION <br /> CERS ID 10154767 Date of MonitoriV9 6rrCxettrtion <br /> Lusiness Name (Same as Faclli N the or A- oing usiness As) Building # LU1 `J <br /> awrence Livermore �i "lionaPtagorafory 879 <br /> Corral Hollow Road <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone # <br /> Thornton Environmental Construction , Inc . 209-834-0792 <br /> Mailing Address <br /> RO . Box 360833 Milpitas , CA 95036-0833 <br /> Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) <br /> Brian Thornton <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> CSLB A, CA 0 , HAZ #724513 5024962- UT 03-26-2020 <br /> Monitoring stem Training and Certifications List all applicable certifications. Expiration Date <br /> veeaera* 111001 Level - a%zUz1 <br /> vneumercator 910208 03z23w=20 <br /> HUNAN # 76960402 11 ZWZ2020 <br /> VIVII s #2010 VIVII 890 lestUnit - - <br /> 111 . RESULTS OF TESTING I SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> Monitoring System Set-up Alarm History Report <br /> Was any monitoring equipment replaced? <br /> (lf "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section ll/ below) El 9 El <br /> Was damage , debris, or liquid found inside any secondary containment systems? <br /> (if "Yes, " describe what was found in section 1V below) R F1 <br /> Is all monitoring equipment operational per manufacturer's specifications? <br /> (if "No, " describe why in section /V below.) <br /> IV. COMMENTS <br /> If directed to use this section, describe how and when the issues were or will be corrected. <br /> 1 -2 quarts of water was found is the unleaded piping sump, the water was removed for disposal during inspection . <br /> The Bravo Float Trip Mechanisms did not operate properly, all (3) had to be cleaned in order to operate freely. <br /> Loss of epoxy coating and corrosion is present. Customer has requested a quote for repairs. <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of <br /> Regulations, Title 23, Division 3, Chapter 16, Section 2638 and all information contained herein is true and accurate. Attached to <br /> this certification is information (e.g. , manufacturers' checklists, monitoring system set-up, alarm history report, etc.) necessary <br /> to verify that this information and the site plan showing the layout of UST system is complete and accurate. <br /> UST Service Technician Signature <br /> CERS = Caldomia Environmental Reporting System, ID = Identification, ICC = Intemationat Code Council, Y = Yes, N = No, NA = Not Applicable <br /> UN407 www.unidoes.org 116 - Rev. 10101118 <br />