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AM <br /> San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:vvww.sigov.org/ehd <br /> Underground Storage Tank Program Inspection Report <br /> Facility Name: Facility Address: Date: <br /> .,anuary 20, 2016 <br /> Overall Inspection Comments: <br /> On site to conduct a routine inspection and witness the annual monitoring system certification testing. <br /> Complete and submit a copy of the Return to Compliance Certification form to the EHD with a statement <br /> documenting the corrective actions that have been or will be taken for each violation, and any supporting <br /> paperwork, by 2-20-16, <br /> Please be aware that as of Januaryl, 2014, facility operators are required to upload the following UST program <br /> documents into the California Environmental Reporting System(CERS): UST Monitoring Site Plan, UST <br /> Certification of Financial Responsibility, UST Response Plan, UST Letter from Chief Financial Officet(if <br /> applicable), and the Owner Statement of Designated Operator Compliance. The UST Owner/Operator: Written <br /> Agreement, if applicable, can be stored at the facility or uploaded into CERS. <br /> FTER THE COMPLIANCE DATE, EHD WILL BILL FOR ALL TIME AND ACTIVITIES ASSOCIATED WITH BRINGING <br /> THIS FACILITY BACK INTO COMPLIANCE <br /> THIS FACJLTry IS SU JECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE <br /> Received By Received By(printed name and title): Dat <br /> (signature): <br /> Inspector Inspector(printed name and title): Inspector Phone: <br /> (signature): r?na; AFP,^,453 <br /> Page 6 of 6 <br />