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Appendix Vlll <br />Underground Storage Tank <br />Spill Container Testing Report Form <br />TYPE OF ACTION On Installation ® Repair M 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10154767 <br />Test Date <br />07-26-2023 <br />Facility Name <br />Lawrence Livermore National Laboratory Bldg. 879 <br />Facility Address <br />15999 W. Corral Hollow Road <br />City <br />Tracy <br />ZIP Code <br />95376 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Thornton Environmental Construction, Inc. <br />Phone <br />209-832-0792 <br />Mailing Address <br />PO 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 ICC Expiration Date <br />5024962 -UT 02-23-2024 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Caldwell Sump Level Change Indicator <br />05-02-2026 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used Components Tested <br />PEI 1200 Spill Containment Bucket <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />I hereby certify that each spill container was tested in accordance with California Code of <br />Regulations, title 23, division 3, chapter 16, section 2637.1; that required supporting <br />documentation is attached; and all information contained herein is accurate. I understand <br />that test procedures shall be made available upon request by the governing authority. <br />Service Technician Signature <br />--- <br />Date <br />07-26-2023 <br />Total # of Pages <br />2 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council <br />Page 1 of 2 <br />