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Appendix IX <br /> Underground Storage Tank <br /> Ove III Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ® 36 Month <br /> 1. FACILITY INKIRMATION <br /> CERS ID Inspection Date <br /> 10402351 10/10/2024 <br /> Facility Name <br /> ARCO AM PM #8 230 <br /> Facility Address City ZIP Code <br /> 1340 W Colony R I. Ripon 95366 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Perform ng the Inspection Phone <br /> Diamond Petrole m Services, Inc. (925) 470-0803 <br /> Mailing Address <br /> 3619 King Ct Antioch— CA 94509 <br /> Service Technician Performing Inspection <br /> Guadalupe Sancliez <br /> Contractor/Tank T ster License Number <br /> 1006444 <br /> ICC Number Expiration Date <br /> 5250451 04/01/2025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FFS EVR PHASE I SYSTEMS - VR -101 02/18/2026 <br /> 4. INSPECTION ROCEDURES INFORMATION <br /> Inspection Procec ures Used Components Inspected <br /> FFS OPV DROP "UBE FORM 87, 91 and Diesel Drop Tubes <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br /> !hereby certify f at 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. !understand <br /> that test proced res shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 10110/2024 13 <br /> CERS = California Environmental Reporting System, 1D = Identification, ICC = International Code <br /> Council, OPE = 0 erfll Prevention Equipment <br /> Page t of 2 <br />