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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 Inspection Date <br /> 10182265 10/11/2021 <br /> Facility Name <br /> ARCO AM PM # 82602 <br /> Facility Address City ZIP Code <br /> 2430 Joe Pombo Pkwy Tracy 95377 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Diamond Petroleum Services, Inc. (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 Expiration Date <br /> 5250451 04/01/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder-Root ATG Technician #A30138 09/29/2023 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> Veeder Root Overfill 87 and 91 TI-Ms <br /> 5. CERTIFICATION BY SERVICE 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 96, 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 Technician Signature Date Total # of Pages <br /> 10/11/2021 13 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />