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AGE F& INSPECTION STATUS FORM&SORO <br />DATE OF INSPECTION kit -6 L18 i <br />Site # (full five digits) CITY <br />AGENCY NAME: <br />Store <br />TYPE OF INSPECTION <br />(Pis check mark one box) <br />Kr (Nozzles/Devices) Weights and Measures El Air (APCD/AQMD/Vapor Recovery) <br />Q1POS/Scanners) Weights and Measures ❑ UST/CUPA/HazMat (Env. Health/Fire Dept) <br />n Storm Water Other. <br />Check box ONLY if 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 NOV$, 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, list as %, 2, 3", etc. on form. <br />ITEM # <br />ADDRESSED <br />@ STATION <br />19!EL? <br />IF NO, WAS <br />SOLVEONE <br />CALLED? <br />SOLVEONE TICKET # <br />CURRENT STATUS/COMMENTS <br />(if item is/has been addressed at station level, <br />indicate how It's been/will be addressed) <br />(M OR NO) <br />N <br />,U <br />/ <br />NO <br />LC, <br />7:! <br />N <br />N, 1-1 <br />0 <br />L4111'e— fi�i 2 C Q W i A Vr <br />C, �1 1 L42 Vj i <br />ry Lk. <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 Steve Coulter ECA at (951)880-0048. <br />(agency inspection report must be a legible copy). <br />Rev: October -2014 <br />