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Appendix V { UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORMPa e 1 o"6 This form must be used to document testing and servicing of underground storage tank (UST) monitoring eautpment. 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 Monitoring Svstam Certification 10181559 6/6/2019 Business Name (Same as Facility Name or DBA Doing Business As. ) Building # Kaiser Manteca Business Site Address Cltv ZIP Code 1777 W. Yosemite Avenue I Manteca 1 196337 11 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performina the Certification Phone # Beishire 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 Contractor/Tank Tester License I ICCCertification # ICC Certification Expiration Date 808313 5252456 7/28/2019 Monitoring S stem Tralnin and Certifications List allaylicable cerfiflcations. Ex iration 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 W Monitoring System Set-up 0 Alarm History Report — — Was any monitoring equipment replaced ? ❑ a ❑ fit "Yes " Identify the specific devices replaced and list the rnanufacturer and model for all replacement parts in section IV below. ) Was damage debris or liquid found inside any secondary containment systems? ❑ Q Q (If "Yes " describe what was found in section iV below. ) Is all monitoring equipment operational per manufacturer's specifications? a ❑ ❑ (if 'No " 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. 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 Regulations title 23 division 3 chapter 16 section 26313 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 verlfv that this information and the site plan showing the layout of UST system is complete and accurate. UST Service Technician Signature ( ;r: OFc _ _