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Appendix'V1 <br /> Underground Storage Tank <br /> Monftoring System Certification Form <br /> TYPE OF ACTION ® Installation Ej Repair El 12 Month 3 ),50 13k-D <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10181239 0910412025 <br /> Facility Name <br /> A A Gas <br /> Facility Address City ZIP Code <br /> 16 E. Harding Waft Stockton 95204 <br /> . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the pertificetion Phone <br /> Elite IV Contractors 1 (209)461-6337 <br /> Mailing Address <br /> 2535 Wigwam Dr. Stockton, CA. <br /> Service Technician Performing Test <br /> Benjamin Malaspina <br /> ontractorlTank Tester License Number <br /> 1001331 <br /> ICC Number ICC Expiration pate <br /> 9519380 06104/2026 <br /> F3. Ti ININC AND CERTIFICATIONS <br /> Nfanufacturerand Test Equipment Training Corlific-ations Certifications Expiration Date <br /> VM 14514 0910912025 <br /> Red Jacket Installer D27440 091041 027 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 hereby certify that the monitoring system is operational ;n accordance with California Code <br /> of Regulations, title 23, division 3, chapter 16, section 2638; that required supporting <br /> documentatiorr is attached; and all information contained herein is accurate. <br /> Service TecInnician Signature Date Total # of Pages <br /> 0910412025 6 <br /> CERS = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br /> IOC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable, SW= ingle- <br /> Walled, UDC = Under-Dispenser Conta€nment, UST = Underground Storage Tank, <br /> VPH = Vacuum/Pressure/Hydrostatic <br /> Page 1 of 6 <br />