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Appendix V1 <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION M Installation ® Repa frI❑Q 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10911469 0211212025 <br /> Facility Name <br /> Grappa Market <br /> Facility Address City ZIP Code <br /> 704 N. Jacktone Rd. Ripon 95366 <br /> 12. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Elite 1V Contractors (209)-461-6337 <br /> Failing Address <br /> 2535 Wigwam Dr. Stockton, CA. <br /> Service Technician Performing Test <br /> Benjamin Malaspina <br /> ContractorfTanlc Tester License Number <br /> 1001331 <br /> ICC Number ICC Expiration Date <br /> 9519380 0614412026 <br /> 3. TRAINING AND CERTIFICATION$ <br /> Manufacturer and Test Equipment Training Certifications expiration Date <br /> Veeder-Root Tech C27440 1211412026 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> ! hereby certify thaf the monitoring system is operational in accordance with California Coote <br /> of Regulations, title Zit division 3, chapter 16, sectivrr 2638; that required supporting <br /> afocumentadon is attached; and$tl information contained herein is accurate. <br /> Bernice Technician Signature Date 'Total# of Pages <br /> �x-- ' 0211212025 2 <br /> CER S = California Environmental Reporting System, G PH = Gallons Per Hour, ID = Identification, <br /> ICC = International Code Council, LLD ;-- Line Leak Detector, NA = Not Applicable, SW;-- Single- <br /> Walled, UDC = Under-Dispenser Containment, UST = Underground Storage Tank, <br /> VPH = Vacuum/Pressure/Hydrostatic <br /> Page 1 of 6 <br />