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SAN <br /> J O A U I Environmental Health Department <br /> COUNT <br /> G'rratrress grows here, <br /> Service Request Inspection Report <br /> Name of Facility: SAFEWAY FUEL CENTER#0055 Date: 09/18/2025 <br /> Address: 19533 S MOUNTAIN HOUSE PKWY, MOUNTAIN HOUSE <br /> Requestor: Telephone: <br /> Program Element: 2308- UST RETROFIT Request#: SR2501392 <br /> Inspection Type: 4320- UST RETROFIT REPAIR INSPECTION <br /> Onsite Service Technician: Steven Ingraham ICC Service Tech/Installer Exp. Date: 3/24/2026 <br /> Manufacturer training: OPW, 07/29/26 <br /> OVERALL INSPECTION NOTES AND COMMENTS <br /> NOTES <br /> -Witnessed 71 SO-41 OCT flapper valve functionality on 87 tank. <br /> -Verified measurement of drop tubes for 95%tank volume shut off. <br /> -Verified Xerxes 30K tank charts and calculations. <br /> The facility is approved to receive fuel in the 87 tank. <br /> The person in charge is responsible for ensuring that the above mentioned facility is in compliance with all applicable sections of the California Health and <br /> Safety Code.If a reinspection is required,fees will be assessed at the current hourly rate. <br /> Received by: Name and Title: Eric Marshall, Manager <br /> EH Specialist: MONICA DE ANDA Phone: (209)616-3063 <br /> FA0027204 SR2501392 SC4320 09/18/2025 <br /> EHD Rev.09/16/2020 Page 1 of 1 Service Request Inspection Report <br />