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San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone. (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> Underground Storage Tank Program Inspection Report <br /> Facility Name: Facility Address: Date: <br /> CHEVRON STATION ##99840* 4344 E Waterloo Rd Stockton December 29 2015 <br /> Overall Inspection Comments: <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 January 28, 2016. <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 /> Notes: A verbal consent to inspect, photograph, and take sample if necessary was given by Julia Kaderlik, store <br /> manager. A minimum of one hour hydrostatic spill bucket testing were conducted on both 87 and 91 tanks and <br /> passed. <br /> Provided: Return to compliance form <br /> ALL EHD STAFF TIME ASSOCIATED WITH FAILING TO COMPLY BY THE ABOVE NOTED DATES WILL BE BILLED AT THE CURRENT HOURLY RATE <br /> THIS FAC LITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE <br /> Received By Received By(printed name and title): Date: _ <br /> (signature): /� o Julia Kaderlik, Store Manager j2-2Q - V <br /> Inspector Inspector(printed name and title): Inspector Phone: <br /> (signature): - CINDY VO, EH Specialist (209)468-8257 <br /> Page 4 of 4 <br />