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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. 1 . FACiLITY INFORMATION CERS ID Date of Monftorinn System Certification 10180977 6/6/2019 Business Name (Same as Facility Name or DBA — Doing Business As. ) Building # Kaiser Stockton Business Site Address c1tv ZIP Code 7373 West Lane Stockton 195210 li . 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.) Jeff Badders Contractorffank Tester License # iCC Certification # ICC Certification Expiration Date 808313 5252456 7/28/2019 Mo Itorin S stem Tralf1ing and Certifications List all a licable cediFcatlons. Expiration Date See Attached III . RESULTS OF TESTINGISERVICING Indicate and attach the following reports If the monitoring aauipment Is capable of aeneradna either. 'Y ,N NA W Monitorinn System Set-up W Alarm History Report — -- -- Was any monitoring equipment replaced? n 0 Q (if "Yas " identify the specific devices replaced and fist the manufacturer and model for all replacement parts in section IV below. J .Was damage debris or liquid found inside any secondary containment systems? Q Q Q (if "Yes " describe what was found in section IV below. ) Is all monitoring equipment operational per manufacturer's specifications? Q F1 E (If Wo, " describe why in section 1V below. ) IV. COMMENTS if directed to use this section describe how and when the Issues were or MY be corrected. V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the equipment identified in this document was Inspectediserviced 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 i i