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Wr San Joaquin County qW <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, California95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www sitloy orp/ehd <br />derqround Storage Tank Program Inspection Report <br />Facility Name: <br />Facility Address: I Date: <br />Overall Inspection Comments: <br />Complete and submit a copy of the Return to Cornpiiance el :uicatio with a <br />documenting the corrective actions that have been or will be taken for each violation, and any supporting <br />paperwork, by June 19, 2015. <br />Please be aware that as of January1, 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 />>LL EHD STAFF TIME ASSDCIAI to VVI i n rraunm ...,..... <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE <br />By k n Received By (printed name and title): 4i�� S <br />(signature): <br />name <br />(signature): -/ <br />Page 5 of 5 <br />Phone: <br />