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Appendix Bill <br />Underground Storage Tank <br />Spic( Container Testing Report Form <br />TYPE OF ACTION 54 Installation t9 Repair ❑ 12 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10181513 03/01/2023 <br />Certification Date <br />Facility Name <br />Ripon CFN <br />Facility Address <br />816 S Frontage Rd <br />City <br />Ripon <br />County <br />Zip Code <br />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 CA <br />Contractor[Tank Tester License <br />Number 1001331 <br />Service Technician Performing Test <br />Benjamin Malaspina <br />ICC Number ICC Expiration Date <br />9519380 06/17/2024 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer & Test Equipment Training Certifications <br />Expiration Date <br />Franklin Fueling EVR Phase 1 1019683711 <br />08/23/2023 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components) Tested <br />Hydrostatic <br />Diesel Fill Bucket <br />5. CERTIFICATION BY THE SERVICE TECHNICIAN CONDUCTING THE TEST <br />1 hereby certifyMat each spill container was tested in accordance with Califomia Code of <br />Regulagons, We 23, derision 3, chapter 16, section 26371, Mat required supporting documentation <br />is attaahed and all informagon contained herein Is accurate. I understand that test procedures shall <br />be made available upon request byMegovemingauthonty. <br />Service Technician Signature <br />L,�c �• — �—� <br />Date <br />Total # of Pages <br />2 <br />CERS= California Environmental Reporting System, GPH= Gallons Per Hour, ICS= Identification, ICG= <br />International Code Council <br />