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Appendix VI UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM ( Page 1 of 6 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 Monitorinq System Certification 10180977 6/6/2019 Business Name (Same as Facility Name or DBA — Doing Business As. ) Building # Kaiser Stockton ZIP Code Business Sita Address C� 7373 West Lane Stockton 95210 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION i Name of Company Performinq the Certiflcation Phone # i Beishire Environmental Services , Inc . (949 ) 460-5200 j Mailing Address 25971 Towne Centre Dr. , Foothill Ranch , CA 92610 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Ceitiflcation.) Jeff Badders ContractorlTank Tester License # ICC Certification # ICC Certification Expiration Date 808313 5252456 7/28/2019 Monitoring System TraInIng and Certifications Lest all applicable cedifications. Expiration Date See Attached III . RESULTS OF TESTING/SERVICING Indicate and attach the following reports if the monitorina equipment is capable of generating either Y N NA W Monitoring System Set-Up 0 Alarm History Report — — Was any monitoring equipment replaced? ❑ Q ❑ (if "Yes, " Identify the specific devices replaced and list the manufacturer and model for all replacement parts in section iV below. ) Was damage debris or liquid found inside any secondary containment systems? ❑ Q ❑ Rf "Yes " describe what was found in section iV below. ) Is all monitoring equipment operational per manufacturer's specifications? a ❑ ❑ (If Wo " describe why in section iV below. ) IV. COMMENTS if directed to use this section describe how and when the issues were or will be corrected. i I I i i V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING . THIS TESTING I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of Regulatlons title 23 division 3 chapter 16 section 2638 and all information contained herein is true and accurate . Attached to this certification is information (e. a ., 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 E