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Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report Form <br />TYPE OF ACTION ❑ Installation ❑ Repair ® 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10402351 <br />Inspection Date <br />10/13/2021 <br />Facility Name <br />ARCO AM PM #83230 <br />Facility Address <br />1340 W Colony Rd. <br />City <br />Ripon <br />ZIP Code <br />95366 <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 />Guadalu a Sanchez <br />Contractor/Tank Tester License Number <br />1005444 <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 ATG Technician # A30138 <br />09/29/2023 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used <br />Components Inspected <br />Veeder Root Overfill <br />87,91 and Diesel TI -Ms <br />5. CERTIFICATION BY SERVICE <br />TECHNICIAN CONDUCTING INSPECTION <br />I hereby certify that the OPE was inspected in accordance with California Code of <br />Regulations, title 23, division 3, chapter 16, section 2637.2; that required supporting <br />documentation is attached; and all information contained herein is accurate. I understand <br />that test procedures shall be made available upon request by the governing authority. <br />Service Techni ' n Signature <br />Date <br />10/13/2021 <br />Total # of Pages <br />13 <br />- U " <br />CERS = California Environmental Re/porting System, ID = Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment <br />Page 1 of 2 <br />