Laserfiche WebLink
Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report Form <br />TYPE OF ACTION ❑Installation ❑Repair x36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10746523 <br />Inspection Date <br />7/19/2021 <br />Facility Name <br />Pershing Holdings Inc. <br />Facility Address <br />1329 Escalon Ave. <br />City <br />Escalon <br />ZIP Code <br />95320 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />Diamond Petroleum Services, Inc. <br />Phone <br />(925) 470-0803 <br />Mailing Address <br />3619 King Ct Antioch, CA 94509 <br />Service Technician Performing Inspection <br />Guadalupe Sanchez <br />Contractor/Tank Tester License Number <br />100544 <br />ICC Number <br />5250451 <br />Expiration Date <br />04/01/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder Root TLS-3XX Technician # A30138 <br />10/05/2021 <br />4. INSPECTIONPROCEDURES INFORMATION <br />InspectionProcedures Used <br />Components Inspected <br />V1R Overfill Testing <br />87 and 91 ATGs <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br />1 hereby certify that the OPE was inspected in accordance with California Code of Regulations, title <br />23, division 3, chapter 16, section 2637.2; that required supporting documentation is attached; and all <br />information contained herein is accurate. 1 understand that test procedures shall be made available <br />upon request by the governing authority. <br />Service Technici 9n Signature <br />"// <br />Date <br />7/19/2021 <br />Total # of Pages <br />12 <br />6. OVERFILL PREVENTION EQUIP ENT DETAILS <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment <br />Page 1 of 2 <br />