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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair M 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10422475 03/25/2024 <br /> Facility Name <br /> Yosemite Avenue Arco Am Pm <br /> Facility Address City ZIP Code <br /> 1711 E Yosemite Ave. Manteca 95366 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Perform ng the Inspection Phone <br /> Diamond Petroleum Services, Inc. (925) 470-0803 <br /> Mailing Address <br /> 3619 Kinci Ct Ant och CA 94509 <br /> Service Techniciai i Performing Inspection <br /> Guadalu a Sanc ez <br /> Contractor/Tank T ster License Number <br /> 1005444 <br /> ICC Number Expiration Date <br /> 5250451 04101/2025 <br /> 3. TRAINING AN CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW Phase I US EVR Tech # 0163755 06/06/2025 <br /> 4. INSPECTION ROCEDURES INFORMATION <br /> Inspection Procec ures Used Components Inspected <br /> OPW Worksheet 87 and 91 Drop Tubes <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br /> I hereby certify t 7at the OPE was inspected in accordance with California Code of <br /> Regulations, titif 1 23, division 3, chapter 16, section 2637.2; that required supporting <br /> documentation i 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 Techniciai Signature Date Total # of Pages <br /> 03/25/2024 12 <br /> CERS = California Environment I Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = O erfill Prevention Equipment <br /> Page 1 of 2 <br />