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Appendix Ill <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION E] Installation Repair © 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10911469 - San Joaquin EMD 1911912024 <br /> Facility Name <br /> Grappa Market - Shell <br /> Facility Address City ZIP Code <br /> 704 N Jack Tone Rd Ripon 95366 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification, Phone <br /> BZ Service Station Maintenance, Inc 916-371-2380 <br /> Mailing Address <br /> 1041 Triangle Dt, W Sacramento, CA 95806 <br /> Service Technician Performing Test <br /> Steven Miller 11 <br /> Contractor/Tank Tester License Number <br /> 433159 <br /> ICC Number [CC Expiration Date <br /> 10323143 217 212026 <br /> 3- TRAINING AND CrERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> VIS TLS - C34532 1216}2025 <br /> VMI LD - 5525 111012026 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that the monitoring system is operational In accordance with California Code <br /> of Regulations, title 23, division 3, chapter 16, section 2635 Mat required supporting <br /> documentation is attached. and aft information contained herein is accurate. <br /> Service Technician Signature Date Total # of Pages <br /> �W49211-- $11912024 1 <br /> CE1 S = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br /> ICC = International Code Council_ LLD = Line Leak Detector, NA = blot Applicable, SW = Single- <br /> Walled, U DC = Under-[dispenser Containment, UST = Underground Storage Tank, <br /> VPH = Vacuum/Pressure/Hydrostatic <br /> Page 1 of 6 <br />