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Appendix VI UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM Pa e 1 of s This form must be used to document testing and servicing of underground storage tank(UST)monitoring equipment. A copy of this form must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local agency regulating the USTs within 30 days of the date of the monitoring system certification. I. FACILITY INFORMATION CERS ID Date of Monitorina Svstem Certification 10181559 1 6/25/2020 Business Name(Same as Facility Name or DBA—Doing Business As.) Building# Kaiser Manteca Business Site Address City ZIP Code 1777 W. Yosemite Avenue Manteca 95337 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone" Belshire Environmental Services, Inc. (949) 460-5200 Mailing Address 25971 Towne Centre Dr. , Foothill Ranch, CA 92610 Name of UST Service Technician Performing the Certification(Print as shown on the ICC Certification.) Mark Riley ContractoriTank Tester License# ICC Certification# ICC Certification Expiration Date 808313 8932714 1/6/2021 Monitoring System Training and Certifications List all applicable certifications. Expiration Date See Attached III. RESULTS OF TESTING/SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA QMonitoring System Set-up Alarm History Report — —Was any monitoring equipment replaced? L Q LJ (If"Yes,"identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below. U Was damage,debris,or liquid found inside any secondary containment systems? (If"Yes,"describe what was found in section IV below.) Ll 21 Lj Is all monitoring equipment operational per manufacturers specifications? a (If"No,"describe why in section IV below.) IV. COMMENTS /f directed to use this section,describe how and when the issues were or will be corrected. V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the equipment identified in this document was inspectedlserviced in accordance with California Code of Regulations.title 23, division 3, chapter 16. section 2638 and all information contained herein is true and accurate. Attached to this certification is information (e.g., manufacturers' checklists, monitoring system set-up, alarm history report, etc.) necessary to verify that this information and the site plan showing the layout of UST system is complete and accurate. UST Service Technician Signature