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Tesoro#68150 200-727-3464 p.1 <br /> AGENCY INSPECTION STATUS PERM <br /> DATE OF INSPECTION 08/28/14 68150 LOCKEFORD <br /> Site A(full five digits) CITY <br /> Guillermo Lopez David Marks <br /> MANAGER RAM <br /> AGENCY NAME: Sari Joaquin County Environmental Health Department <br /> Full Name of Agency.Include the County,City or State name. <br /> TYPE OF INSPECTION NON-ENVIRON MENTALIRetail) ENVIRONMENTAL <br /> (Pis check markow 6or) pnsertall imo-mspeolons Binder") (insertall lntogold-Enviro'imental Binder') <br /> ❑ Health(Retail/Market/Food) ❑ Air(APCD/AQMDNapor Recovery) <br /> ❑ (POS/Scanners)Weights and Measures ❑ (Nozzles/Devices)Weights and Measures <br /> ❑ Alcohol UST/CUPA/HazMat(Env.Health/Fire Dept) <br /> E] Tobacco ❑ Storm Water <br /> ❑ Other: ❑ Other: <br /> Check box ONLY H the agency's Inspection report DOES NOT have any notice of violations or notice to comply Items listed on report. <br /> ❑ otherwise,please follow directions below(even if the items were addressed at the time of inspection,each item must be <br /> listed below.): <br /> IF INSPECTION REPORT IS NOTED WITH NOVS NOTICE TO COMPLY ITEMS.ETC,PLEASE FILL OUT THE REST OF THE FORM BELOW. <br /> "Item#(s)on form should correspond with item#(s)on the inspection report. <br /> If the items are not numbered on the report,Islas%,2,3",etc.on form. <br /> U Cl1RRWSTATUS/[DIv1ME31C� <br /> ienitPseta - - <br /> ':'tEvfta tf:,yowAs - _ (dfitemTs/hasbeeri`addresseda€statf0ri:level, - <br /> SotvroNe tndicatei hove ft's beeD/wi�"kiiressed► , <br /> r. .= <br /> 7rtKt t- - oRNo ckliki?'. - s EONETIe'ia'rV -. <br /> Revision has to be made in the California Environmental Reporting System <br /> I notified Steve Coulter <br /> R NO <br /> Once completed,fax both the Status Form (Status Form as the coversheet)and the agency's inspection report in a timely manner,as <br /> most inspections are time sentitive Fax to:866.227.1742 <br /> (aeencv inspection report must be a leeible cony). <br /> Rev:Apr1l-2PI3 <br />