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Appendix Vi <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION T] Installation repair F1 12 Month <br /> 1. FACILITY INFORMATION <br /> DERS ID Certification Date <br /> 109/1469 0312012025 <br /> Facilitp Name <br /> Grappa Market <br /> Facility Address city ZIP Code <br /> 704 N. ,hack Tone Rd Ripon 95366 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Elite IV Contractors (209)-461-6337 <br /> Mailing Address - <br /> 2535 Wigwam Dr. Stockton, C.A. 95205 <br /> Service Technician Performing Test <br /> Benjamin Malaspina <br /> Contractor/Tank Tester License Number <br /> 1001331-A <br /> ICC Number ICC Expiration Date <br /> 9519380 10610412026 <br /> 3. TRAINING AND CERTIFI ATION <br /> Manufacturer and Test Equipment Training Gedifications Expiration Date <br /> Veeder-Boot 027440 9211412026 <br /> 4. CERTIFICATION BY S E RVIC ETECHNICIAN CONDUCTING TEST <br /> 1 hereby certify that the monitoring system is operational err accordance with California Code <br /> of Regulations, title 23, division 3, chapter 16, section 2638; that required supporfingr <br /> documentation is attached; and all information contained herein is accurate. <br /> Service Technician Signature Date Total # of Pages <br /> 1411--� 0312012025 2 <br /> ERS = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification. <br /> ICC = International Code Council, LLD = Line Leak Detector, NA ;-- Not Applicable, SW = Singfe- <br /> Walled, UDC = Under-Dispenser Containment, UST = Underground Storage Tank, <br /> VPH = 1lacuumlPressure/Hydrostatic <br /> Page 1 of 6 <br />