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•SA6JOAQIJIN Environmental Health Department <br /> C-0UNTY <br /> U'fiderloit � e Tank Program Inspect10n <br /> Facility Name: Facility Address: Date: <br /> COUNTRYSIDE LIQUORS & GAS 14971 N HWY 88 , LODI TMarch 29, 2018 <br /> paperwork, by April 28, 2018. <br /> Please be aware that as of January 1, 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 Officer(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 /> AFTER THE COMPLIANCE DATE, EHD WILL BILL FOR ALL TIME AND ACTIVITIES ASSOCIATED WITH BRINGING <br /> THIS FACILITY BACK INTO COMPLIANCE. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE <br /> Received by: Date: March 29, 2018 Inspector: Inspector Phone: <br /> va <br /> Printed Name and Title: CESAR RUVALCABA, EH Specialist (209) 953-6213 <br /> Bikram Sodhi, Manager <br /> FA0000540 PR0231911 SCO01 03/29/2018 <br /> EHD 23-01 Rev.10/31/2017 Page 4 of 4 Underground Storage Tank Program OIR <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />