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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Pagel of 6) <br /> Fa :q <br /> st be used to document testing and 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 /> atin the USTs within 30 days of the date of the monitoring system certification . <br /> I. FACILITY INFORMATION <br /> CERS ID 10154767 Date of Monitorir�q,S �r►� e[tcation <br /> siness Name $ame as Facili N pre or A- orng usiness As) Building <br /> # L 11 <br /> Luawrence evermore �la�ionaPLaDoratory 882 <br /> I` '996 0. Corral Hollow Road Macy <br /> ll. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Com any Performing the Certification Phone # <br /> Thornton Environmental Construction , Inc. 209-834-0792 <br /> Mailing Address <br /> P. O . 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, C- 10 , HAZ #724513 5024962- UT 03-26-2020 <br /> - Monitoring System Training and CertificationsList all a licable cenNcations. Expiration Date <br /> ee er- oo eve - - <br /> e er r -20 <br /> RONAN 976960402 11 w06�20, <br /> VMI s #2010 VIVII 890 lestUnit M09mozo <br /> III. RESULTS OF TESTING / SERVICING <br /> Indicate and attach the following reports ff 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? El ® El <br /> "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) <br /> Was damage, debris, or liquid found inside any secondary containment systems? ❑ © ❑ <br /> (If `Yes, " describe what was found in section W below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? ® ❑ <br /> (If "No, " describe why in section IV below.) <br /> IV. COMMENTS <br /> If directed to use this section, describe how and when the issues were or will be corrected. <br /> This system does not have a printer, a copy of the Alarm Log is attached . <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 = Caf ria Eff ronmental Reporting System, ID = Iden�, ICC = International Code Council, Y = Yes, N = No, NA = Not Appkable <br /> UN-107 www.unidoes.org 116 - Rev. 10/01/18 <br />