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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: 09/23/2022 <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: 06/16/2023 <br /> Manufacturer training: VR, 07/20/23 <br /> OVERALL INSPECTION NOTES AND COMMENTS <br /> NOTES <br /> On site inspection: <br /> -Witnessed leak detector test on 87, 91 and diesel lines <br /> -Witnessed monitoring system functionality.All passed except for S10 high liquid and S16 high liquid. <br /> -Verified vacuum zones <br /> Please schedule an appointment for EHD to verify S10 and S16 liquid sensor functionality. <br /> The following must be submitted to EHD prior to approval to operate (see approval letter dates December 3, 2021 section 5 q-r <br /> and section 8-10): <br /> 1.As-built drawings <br /> 2. Manufacturer tank checklists <br /> 3. Completed designated operator Facility Employee Training Certificate for employees <br /> 4. Certification of Installation/Modification form submitted into CERS <br /> 5. Update in CERS-revising piping sensor from 301 to 304 <br /> 5.All outstanding up-to-date fees paid <br /> Please submit all test results within 30 days of test completion to EHD. <br /> To minimize person to person contact EHD is choosing to write the name of person receiving the report instead of having them <br /> sign. <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 09/23/2022 <br /> EHD 23-01 Rev.07/05/2022 Page 1 of 1 Underground Storage Tank Program Service Request Inspection Report <br />