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Appendix A <br /> Underground Stowage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ff] Installation Repair ® 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 10911469 1211912024 <br /> Facility Name <br /> GE2ppa Market <br /> ILLacility Address City ZIP Code <br /> 704 N. Jack Tone Rd. Ripon 195366 <br /> 12. SERVICE TECHNICIAN INFORMATION <br /> Compare Pertormin.g the Certification Phone <br /> Elite IV Contractors (209)-461-6337 <br /> Mailing Address <br /> 2535 Wigwam Dr. Stockton, CA. <br /> Service Technician Performing Test <br /> Benjamin Malaspina <br /> ContractorlTank Tester License Number <br /> 11001331 <br /> ICO Number ICC Expiration Date <br /> 9619380 06104I2D2 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training CerifficaUons Expiration Date <br /> lfeeder=Root Tech 027440 1211412026 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> i hereby certify that the monitoring system is operational in accordance with California Come <br /> of Regulations, title 23, division 3, chapter 16, section 2638; that required supporting <br /> documenta#lora is attached; and all information contained herein is accurate. <br /> Service Technician Signature Date Total # of Pages <br /> 121l 912024 <br /> C E RS = California Environmental Deporting System. GP = GaIIons Per Hour, iD = Identification, <br /> ]CC = International Cede Council, LLD = Line Leak Detector, NA = loot Applicabie. SPIV= Single- <br /> Wailed, UDC = Under-Dispenser Containment, UST = Underground Storage Tank, <br /> VPH = 1lacuufmlPressurelF-lydrostatic <br /> Page I of <br />