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°• Environmental Health Department <br /> �. �J r� SHAWN <br /> t 7Y - L. <br /> Y <br /> ttlir- ' COUNTY— <br /> Greol less grows he: . . <br /> Underground Storage Tank Program Service Request Inspection Report <br /> Name of Facility: SAFEWAY 0055 FUEL Date: 09/15/2022 <br /> Address: 19533 S MOUNTAIN HOUSE PKWY, MOUNTAIN HOUSE 95391 <br /> Requestor: STIG WERELIUS, STANTEC ARCHITECTURE, INC. Telephone: (707)774-8333 <br /> Program Element: 2303-UST/PIPING INSTALLATION Request#: SR0083832 <br /> Inspection Type: 298-UST RETROFIT REPAIR INSPECTION <br /> Onsite Service Technician: Nicholas Adamitz ICC Service Tech/Installer Exp. Date: 09/16/2023 <br /> Manufacturer training: VR, 07/20/23; FF, 03/15/24 <br /> OVERALL INSPECTION NOTES AND COMMENTS <br /> NOTES <br /> Leslie Henderson <br /> ICC 3/28/2023 <br /> OPW 10/15/2022 <br /> On site inspection: <br /> -Verified dispenser footprints contained by UDCs <br /> -Witnessed sensor functionality <br /> -Witnessed spill container 1 hour hydrostatic testing on the 87, 91 and diesel tanks <br /> -Verified 5-gallon capacity on spill container and proper drainage on the 87, 91 and diesel tanks <br /> -Verified overfill prevention measurements on the 87, 91 and diesel tanks <br /> -Verified communication at all end points <br /> Vacuum zones to be tested at final inspection. Submit updated vacuum zone plans for EHD approval.Vacuum zones will be <br /> verified at final inspection. <br /> Additional inspections are required. Please see approval letter dated December 3, 2021, section 5 for full list of inspections. <br /> Please submit inspection requests in writing to UST@sjgov.org with 48-hour advanced notice. <br /> Facility is approved to receive fuel in the 87, 91 and diesel tanks. <br /> Note: The CDTFA(formerly BOE)number listed in CERS is missing a digit. Please re-submit CERS with the missing digit <br /> added to the CDTFA number in CERS. <br /> Inspection report emailed on 9/19/2022. <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: Emailed to Les Henderson, Contracto <br /> EH Specialist: CAROL PRESTO Phone: (209)616-3061 <br /> SR0083832 SC298 09/15/2022 <br /> EHD 23-01 Rev.07/05/2022 Page 1 of 1 Underground Storage Tank Program Service Request Inspection Report <br />