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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION E] Installation rl Repair ® 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10154767 <br />Certification Date <br />07-26-2023 <br />Facility Name <br />Lawrence Livermore National Laboratory Tanks 879-TFUG01 & 879-TFUD01 <br />Facility Address <br />15999 W. Corral Hollow Road Bldg. 879 <br />City <br />Tracy <br />ZIP Code <br />95376 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />Thornton Environmental Construction, Inc. <br />Phone <br />209-834-0792 <br />Mailing Address <br />P.O. Box 360833 Milpitas, CA 95036-0833 <br />Service Technician Performing Test <br />Brian Thornton <br />Contractor/Tank Tester License Number <br />CSLB #724513 A, C-10, HAZ <br />ICC Number <br />5024962 -UT <br />ICC Expiration Date <br />2-23-2024 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder-Root Level 4 #A31562 <br />04-04-2025 <br />Pneumercator #10208 <br />09-14-2024 <br />Ronan #7690402 <br />11-04-2024 <br />VMI MLD's #2010 VMI 890 Test Unit #2009 <br />12-26-2024 <br />4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />I hereby certify that the monitoring system is operational in accordance with California Code <br />of Regulations, title 23, division 3, chapter 16, section 2638, that required supporting <br />documentation is attached, and all information contained herein is accurate. <br />Service Technician Signature <br />— <br />Date <br />07-26-2023 <br />Total # of Pages <br />10 <br />CERS = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br />ICC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable, SW = Single - <br />Walled, UDC = Under -Dispenser Containment, UST = Underground Storage Tank, <br />VPH = Vacuum/Pressure/Hydrostatic <br />Page 1 of 6 <br />