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zo 1�a <br /> Appendix 111 � <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION El Installation Repair El 12 Month <br /> 1. FACILITY INFORMATION <br /> CEF S ID Certification Bate <br /> 10511469 10113112025 <br /> Facility Name <br /> Grappa Market <br /> Facility Address City ZIP Code <br /> 704 N. Jack Tone Rd. Ripon 195366 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Elite IV Contractors 1 (209)-461-6337 <br /> Mailing Address <br /> 2535 Wigwam Dr. Stockton, CA. 95205 <br /> Service "technician Performing Test <br /> Benjamin Malaspina <br /> ContractorfTank Tester License Number <br /> 100133'1-A <br /> COO !Number ICC Expiration Date <br /> 5519380 0610df2826 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Cale <br /> !feeder-Root Tech 027440 1211412026 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify than the monitoring system is operational In accordance with Callfomia Code <br /> of Reg uladons, title 23, division 3, chapter fib, section 2688, that required supporting <br /> documentation is attached and all information contained horein is accurate. <br /> Service Technician Signature Date Total # of Pages <br /> Z/'3� 01/3112025 2 <br /> CERS = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br /> ICC = International Code Council, LLD = Line Leah Detector, NA = Not Applicable, SW = Single- <br /> Walled, UDC = Under-Dispenser Containment, UST = Underground Storage Tank, <br /> VPH = 1lacuumfPressurelHydrostatic <br /> Page 1 of <br />