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Appendix VI (Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca.gov.) MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, 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: Kaiser Manteca Bldg. No.: Site Address: 1777 W. Yosemite Avenue City: Manteca Zip: 95337 Facility Contact Person: Sam Corbin Make/Model of Monitoring System: Veeder-Root TLS -350 Contact Phone No.: Date of Testing/Servicing: 6/27/2017 B. Inventory of Equipment TestediCertifled Check the appropriate boxes to Indicate speoif[a equipment inspected/serviced: Tank ID. T1 Diesel Tank AST Tank Id: T2 UST Diesel In -Tank Gauging Probe. Annular Space or Vault Sensor. Piping Sump I Trench Sensor(s). Fill Sump Sensor(s). Mechanical Line Leak Detector. Model: MAG PI Model: Model: 794380-208 Model: _ Model In -Tank Gauging Probe. Annular Space or Vault Sensor. Piping Sump / Trench Sensor(s). Fill Sump Sensor(s). Mechanical Line Leak Detector. Model: Model: Model: 794380- 03 794380-208 Model: Model. f/ J V V Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: Other (s ci a ui ent and model Section E on Pa e 2 : Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor. Model: Annunciator Other (specify a ui ent type and model n Section E on Pae 2). TanklD: TanklD: In -Tank Gauging Probe. Annular Space or Vault Sensor. Model: Model: In -Tank Gauging Probe. Annular Space or Vault Sensor. Model: Model: Piping Sump / Trench Sensor(s). Model: Piping Sump / Trench Sensor(s). Model: Fill Sump Sensor(s). Model: FlII Sump Sensor(s). Model: Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model: Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model: Tank Overfill / High -Level Sensor, Model: Tank Overfill/ High -Level Sensor. Model: Others ifX a ui ent a and model in Section E on Pa e 2)_ Other LsgecffX egulgMent tXEe and model in Section E on Pae 2 . Di penser Dispenser Containment Sensor(s). Model: DispenserID: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). H Dispenser Containment FloatLsl and Chains . UISEMser Containment Floats and Chains . Dispenser 10: Dispenser Containment Sensor(s). Shear Valve(s). Model: Dispenser ID: Dispenser Containment Sensor(s). Model: Shear Valve(s). J Dispenser Containment Fioat(s) and Chains . Dispenser Containment Floats and Chains . Dispenser lD: Dispenser Containment Sensor(s). Model: Dispenser ID: Dispenser Containment Sensor(s). Model: Shear Valve(s). Shear Valve(s). H Dispenser Containment Floats and Chains Dispenser Containment Floats and Chain(s). the facility contains more tanks or dispensers, copy this form. Indude information for everytank 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 Piot Plan showing the layout of moni.torin equipment. For any squipmem capable of generating such reports, i have also attached a copy of the report; (checkoff that app/y): ri systern set-up ® Alarm history report Technician Name (print): David Walker Certification No.: A32030 Testing Company Name: Belshire Environmental Services, Signature:��w=��------ License. No.: 808313 Inc. Phone No.:( 949 ) 460-5200 Testing Company Address: 25971 Towne Centre Dr. , Foothill Ranch, CA 92610 Date of Testing/Servicing: 6/27/2017 Monitoring System Certification Page i of 4 12107