HomeMy WebLinkAboutCUPA REPORT 2016BAKERSFIELD FIRE DEPARTMENT
Prevention Services Division
Underground Storage Tank Program 2101 H Street
DW Inspection Report Bakersfield, CA 93301
Permission to Inspect: Phone: 661-326-3979
Fax: 661-852-2171
Business Name: A-1 FOOD STORE-15-021-36046
Date:6/15/2016
Address Name: 1200 H St-Ajmail Sangha
Inspector Name: Shane Gardner #8248557
Inspection Type: Routine �
E Report: Final
NVO = No Violation Observed OUT = Out of Compliance NA = Not Applicable UD = Undetermined
COS = Corrected On Site RPT = Repeat Violation
Violation
Program Requirement
'8 1
4) 0
SOC
Comments
No
0
0
10'-.
14-1 75
0
2
0
z
V
a
(D!;
File Review
Facility Tank Information
2030021
Facility has a valid Permit
Tank 1-20000-DW-REG
to Operate from the
Tank 2-20000-DW-PRM
CUPA - 23 CCR 16 2712(1);
❑
EJ
E-1
[--j
None
Tank 3-
HSC 6.7 25284
Tank 4-
2010010
UST Operating Permit
missing tank info in cers
Application for Facility
update facility info to include
information and Tank
EPA ID
information
1-1
❑
❑
❑
None
submitted/maintained - 23
CCR 16 2711; HSC 6.7
25286(a)
2010001
Current BOE number
submitted to the CUPA
El
❑
❑
❑
❑
None
and/or CERS - HSC 6.7
25286(c)
2030011
UST compliance
statement and/or
Designated Operator
❑
❑
❑
❑
None
current certification
submitted - 23 CCR 16
2715(a), 2715(b)
2030046
A complete and accurate
response plan has been
submitted, approved and
F-1
❑
❑
❑
❑
None
maintained - 23 CCR 16
2632, 2634(e), 2641(h),
2712 ()1
2030041
A complete and accurate
plot plan has been
submitted, approved and
[ 0
❑
❑
❑
F-1
El
Minor
maintained - 23 CCR 16
2632(d)(1)(C), 2711(a)(8)
2010006
Owner/Operator has not
made false statements or
representation on any
❑
None
required document - HSC
6.725299
2010003
Owner/Operator has a
DO and/or informed the
CUPA of any change (s)
None
within 30 days - 23 CCR
16 2715(a)
Violation
Program Requirement
00
SOC
Comments
No
D
CO)
0
a.
co Z
z
0
z
Testing
2030002
Owner/Operator has
tested and certified leak
�
El
❑
❑
❑
F-1
None
detection equipment
annually - 23 CCR 16 2638
2030048
Secondary containment
testing conducted every
36 months in accordance
❑
❑
None
with requirements - 23
CCR 16 2637
2030055
Spill buckets have been
tested annually as
None
required - HSC 6.7 25284.2
2010009
Secondary containment
test results submitted to
the CUPA within 30 days
None
after the test - 23 CCR 16
2637(e)
2030064
CUPA was poperly
notified within the
prescribed number of
None
hours prior to testing - 23
CCR 16 2637(1), 2638(e),
2643(8), 2644.1(a)(4)
Install/Repair
2060009
Permits obtained to
install, replace, repair, or
❑
❑
❑
❑
❑
None
modify part of the UST
syste - 23 CCR 16 2712
UST System Observation
General Monitoring
2030003
Leak detection system
maintains continuous
RD
monitoring that activates
F]
❑
❑
❑
❑
None
❑
an audible and visual
Yes
alarm - 23 CCR 16 2632,
2634, 2636, 2666
2030016
The annular space of the
tank, piping and sumps
are continuously
RD
monitored and activates
None
F-I
the alarm - 23 CCR 16
Yes
2631(8), 2632(c) (2)(A) &(8),
2633(c), 2636(o
2030017
Product piping outside the
UDC is fail-safe and shuts
down the pump or
❑
❑
❑
❑
❑
None
restricts flow - 23 CCR 16
2636(0(5)
2030018
Turbine sump monitor
activates an audible and
RD
visual alarm or stops the
❑
None
❑
flow of at the dispenser -
i
Yes
23 CCR 16 2636(0(1)
1
1
Underground Storage Tank Program - DW Inspection Report v 2.0
Violation
Program Requirement
o
SOC
Comments
No
42
z
o
z
0
�
o>
2030019
Monitoring system in the
UDCs activates an
audible and visual alarm
❑
❑
❑
❑
❑
None
or stops the flow at the
UDC -23 CCR 16
2636(0(1).
2030043
Leak detection equipment
properly programmed or
RD
properly operated - 23
[
❑
❑
❑
❑
❑
None
❑
CCR 16 2632, 2634, 2636,
(
Yes
2666
2060005
System constructed with
a monitoring system
capable of detecting entry
n
❑
❑
❑
❑
❑
None
into secondary
containment - HSC 6.7
25291(b)
2060014
Correct leak detection
equipment installed for
RD
the type of system
❑
❑
❑
❑
❑
None
❑
present - 23 CCR 16 2638,
Yes
HSC 6.7 25290.1, 25290.2,
25291
2060015
Sensor located in the
RD
proper position /location -
❑
❑
❑
❑
❑
None
F-1
23 CCR 16 2630(d), 2641(a)
(
Yes
2030062
Facility is in compliance
with not tampering with or
RD
disabling leak detection
rm
❑
❑
❑
❑
❑
None
❑
devices or alarms - HSC
T
Yes
6.7 25299(a)(9)
2060022
System constructed with
a monitoring system
capable of detecting entry
❑
❑
❑
❑
❑
None
into secondary
containment - HSC 6.7
25290.2(d)
2030034
Tag /sticker on affixed
monitoring equipment
being certified, repaired,
❑
❑
❑
❑
❑
None
or replaced - 23 CCR 16
2638(
VPH Monitoring VPH
2030065
Interstitial monitoring of
the annular spaces of the
RD
UST is properly
❑
❑
®
❑
❑
❑
None
❑
maintained - HSC 6.7
Yes
25290.1 e
2060023
System constructed with
a monitoring system
capable of detecting entry
into secondary
❑
❑
®
❑
❑
❑
None
containment - HSC 6.7
25290.1(d)
Underground Storage Tank Program - DW Inspection Report v 2.0
Violation
Program Requirement
4-
0 0
SOC
Comments
No
0
>
0
0
M
0) .3
Z
0
Z
Line Leak Detector
2060012
Line leak detector
installed on pressurized
RD
piping system - HSC 6.7
None
❑
25290. 1 (h), 25290.2(8),
252910, 25292(e),
Yes
2636(0(2)
2030026
Line leak detectors detect
a 3 gph leak and/or
RD
audible and visual alarm
None
❑
function properly - 23
CCR 16 2636(0(6),
Yes
2666(c)
2030027
Turbine shuts down when
a leak is detected or
RD
when line leak detector is
None
❑
disconnected - 23 CCR 16
Yes
2666(c)
2030025
Pressurized piping able to
detect a 3.0 gph leak
RD
within an hour, and
None
[:1
restricts the flow or
Yes
alarms - 23 CCR 16
2636(0(2)
Secondary Containment
2060010
UST storing a hazardous
RD
substance has secondary
❑
❑
❑
❑
❑
None
❑
containment - HSC 6.7
Yes
25292
Underground Storage Tank Program - DW Inspection Report v 2.0
Violation
Program Requirement
4-
0 0
0
SOC
Comments
z
In
(0)
0
1--
iL
4)
=No
� o
0
Z
W
>
2030008
UDC, sumps, and/or
other secondary
containment in good
None
condition and/or are free
of debris/liquid - HSC 6.7
25290.1, 25290.2, 25291
2030040
Secondarily contained
RD
piping maintained to allow
❑
❑
❑
❑
❑
None
❑
liquid to drain into sump -
Yes
23 CCR 16 2630(d), 2641(a)
2060006
Secondary containment
piping slopes back to the
❑
❑
None
collection sump - 23 CCR
16 263(c)
2030047
Secondary containment
maintained tight and has
been confirmed by testing
None
- 23 CCR 16 2662, HSC 6.7
25290.1(c)(2), 25290.2(c)(2),
25291 a , 25292(e)
2030060
Entry fittings in secondary
containment for UST
system maintained
None
tight/sealed - 23 CCR 16
2630, 2635(d), 2636(c),
2666
2060020
Spill bucket is installed
and has a functional drain
RP
valve or other means to
None
❑
remove liquid - 23 CCR 16
Yes
2635(b), 2665
2030054
Spill bucket maintained in
RP
good condition and free of
None
❑
debris and/or liquid - 23
Yes
CCR 16 2635(b), 2715(c)(2)
2060019
Spill bucket to has a
minimum capacity of five
None
gallons - 23 CCR 16
2635(b), 2665
Overfill
2030035
UST system is operated
to prevent unauthorized
RP
release, including spills
'�
❑
❑
❑
None
❑
and overfills - HSC 6.7
Yes
25292.1 (a)
2030036
Overfill prevention system
has not been overridden
RP
and meets overfill
1:1
❑
1:1
❑
❑
None
❑
requirements - 23 CCR 16
Yes
2635(b)(2), 2665
Underground Storage Tank Program - DW Inspection Report v 2.0
Violation
Program Requirement
o
SOC
Comments
No
z
O
z
M
V
w
o>
On Site
Records
Certifications
2030023
Required designated
operators or contractors
maintain a proper and
3
❑
❑
❑
❑
❑
None
current ICC certification -
23 CCR 16 2715
2030024
Service technician,
installer, and/ or
employee maintain a
121
❑
❑
❑
❑
❑
None
proper license - 23 CCR
162715
2030031
Employee or contractor
obtained and maintained
proper manufacturer
❑
❑
❑
❑
❑
None
certification - 23 CCR 16
2715
2010007
Submit/maintain current
Certificate of Financial
Responsibility /mechanism
of financial assurance -
❑
❑
❑
❑
❑
None
23 CCR 16 2711; 23 CCR
18 2808.1, 2809 - 2809.2;
HSC 6.7 25292.2, HSC
6.75 25299.30- 25299.34
Designated Operator
2010004
Copies of DO inspections
for last 12 months and list
of trained employees
❑
❑
❑
❑
D
None
maintained - 23 CCR 16
2715
2030013
Designated operator
properly conducted the
monthly inspection and
L?5
❑
❑
❑
❑
❑
None
the reports are complete -
23 CCR 16 2715
2030010
DO notified operator of
any condition observed
during the monthly
D
❑
❑
❑
❑
None
inspection that may
require action - 23 CCR 16
2715(d)
2030012
DO employee training
performed, current for at
least one employee on
❑
❑
❑
❑
❑
None
site, and a log kept - 23
CCR 16 2715(c) (6), 2715(1)
Underground Storage Tank Program - DW Inspection Report v 2.0
Violation
Program Requirement
4-
0
0.0
so_ C
Comments
No
::�.
I--
:)
<
a
ca
0
0.
Q) 0
f Z
0
Z
Oj
Logs
2030001
Leak detection alarm
logs, maintenance and
RD
records of appropriate
1:1
❑ El
❑ El
❑ 0
❑ 0
None
1:1
follow-up actions
maintained - 23 CCR 16
Yes
2632, 2634, 2712(b)
Maintenance/Tests
2010008
Monitoring, maintenance,
repairs, linings, and
RD
upgrade records
❑
❑
❑
❑
❑
None
❑
maintained for the proper
Yes
time period - 23 CCR 16
2712(b)
Documentation
2030033
Failure to maintain on site
an approved monitoring
1:1
❑
None
plan - 23 CCR 16 2632,
2634, 2711, 2712(1)
2030037
Written agreement
between the tank owner
and tank operator to
monitor the tank system
❑
❑
❑
1:1
❑
None
is maintained - 23 CCR 16
2620(b); HSC 6.7
25284(a)(3)
2030061
Suspected or actual
unauthorized release
RD
reported in appropriate
❑
❑
❑
None
❑
time frame - HSC 6.7
Yes
29294,29295
General Operating Requirements
Permit Condition/Approval
2030039
Compliance with all
operating permit
None
conditions - 23 CCR 16
2712; HSC 6.7 25299
2030059
UST system maintained
in accordance with
exclusion/exemption
None
status - HSC 6.7 25281.6,
25283.5
2030014
Owner/Operator received
approval and has
implemented a training
❑
❑ 1:1
None
program at an unstaffed
facility - 23 CCR 16
2715(o
2030015
Facility exhibited that the
method used to monitor
the tank meets the
monitoring methods in
4�
❑
❑
❑
❑
❑
None
2643(f) - 23 CCR 16 2643
Underground Storage Tank Program - DW Inspection Report v 2.0
Violation
Program Requirement
4-
0
0 0
SOC
Comments
No
0>
0
0 = R
12 ,
z
0
z
D
0
W
Red Tag
2030045
Red Tag information is
legible and has not been
❑
❑
None
tampered with - 23 CCR
16 2 717. 1 (g)
2030044
Facility did not allow for
deposit of petroleum into
a UST that has a red tag
None
affixed to the fill - 23 CCR
162717.1(0
Install/Repair
2060024
UST system is made of or
lined with materials that
are compatible with the
1�
El
El
0
❑
❑
None
substance stored - 23
CCR 16 2631.1
2060021
Striker plate installed and
positioned correctly - 23
None
I
CCR 16 2631(c), 2662(d)
ElThere were no violations noted for this inspection.
❑This report shall serve as a "NOTICE TO COMPLY" for Minor Violations, and a "NOTICE OF VIOLATION" for
Major violations. You are, hereby, ordered to correct the above noted violations within 30 days, or according to
correction summaries provided. Formal enforcement and/or penalty assessment may be initiated for any
violations noted, and for those not corrected in a timely manner. (NOTE: If this is a preliminary report, a final report
will follow.)
Inspectors Signature: Date:
Inspector: Enter # of Violations: RD: RP:
Check one box for facility Significant Operational Status (SOC) to be reported to SWRCB and US EPA:
r-1 SOC with both Release Detection and Release Detection (Facility has no Release Prevention and no Release
Prevention Violations)
r-1 Not in SOC (Facility has both Release Prevention and Release Detection Violations)
❑SOC with Release Detection only (Facility has no Release Detection violations but one or more Release Prevention
violations)
❑ SOC with Release Prevention only (Facility has no Release Prevention violations but one or more Release Detection
violations)
Underground Storage Tank Program - DW Inspection Report v 2.0
C
BAKERSFIELD FIRE DEPARTMENT
HAZARDOUS WASTE
_.
Prevention Se1'ViCeS
UNIFIED PROGRAM CONSOLIDATED FORMS
B
BRsFIf zD
2101HStreet
SMALL QUANTITY HAZARDOUS
FIRff `,
Bakersfield, CA 93301
WASTE GENERATOR INSPECTION
i
*ARTNI
Phone: 661 -326 -3979 • fax: 661 -852 -2171
j
! Facility Name; ° cC a �r-
i
Hazardous waste determination made for all wastes <
0 Analysis- enerator Knowledge [CCR 66262.401
Date:'
Site Address: 1 7.. Q C'
Time In: Time Out:
i Owner /Operator: 4.7 -A -1 4,, f ", ! f p
Phone:
EPA ID #
Type of Inspection
0 Routine 0 Re- inspection/Follow -up ombined Routine Inspection
< 0 Joint pection 0
Complaint 0 Focused 0 Other
0 CONSENT TO INSPECT GRANTED BY (Name / Title):
-
Inspection may involve obtaining photographs, review and cop�"ig of records,
and determination of compliance with hazardous waste handling requirements.
C = Complaint: V = Class 1,11 or Minor Violation
Manifests/Consolidated Manifest receipts complete [CCR 66262.23(a)]
3010008
Blue co (s) of manifest mailed to DTSC [CCR 66262.23(a)(4)]
3010011
C
V
HAZARDOUS WASTE REQUIREMENT
N/A
CERS
Violation #
COMMENTS
Recordkee in documentation
Generator has an EPA ID number HSC 25143.131
3010002
Ae
Hazardous waste determination made for all wastes <
0 Analysis- enerator Knowledge [CCR 66262.401
3030005
Contingency lan information posted near phone CCR 66262.34(d)(2)]
3010022
Facility personnel demonstrate training/awareness [CCR 66262.34(d)(2)]
3020001
Manifests/Consolidated Manifest receipts complete [CCR 66262.23(a)]
3010008
Blue co (s) of manifest mailed to DTSC [CCR 66262.23(a)(4)]
3010011
Bills of Lading/receipts available [CCR 66262.40(a)]
-
3010010
LDRs available and complete CCR 66268.7(a)]
3030006
Onsite recycling reported usin UPCF [HSC 25143. 101
3030001
Container /tank management
Containers are in good condition CCR 66262.34(d)(2)]
3030013
Containers are closed except when adding/removing [CCR66262.34(d (2)j
3030017
Satellite containers at or near point of generation [CCR 66262.34(e) 1 A
Em t containers are em CCR 66262.34(f)]
3030007
Containers inspected weekly [CCR 66262.34(d)(2)
3030019
Tanks inspected daily CCR 66262.34 d 2 , 40CFR 265.201
3030027
One container per waste stream at satellite area CCR 66262.34(d)(2)]
3030022
Exclude recyclable materials stored in accordance with local ,
ordinance/hazardous materials codes HSC 25143.101
3010016
Accumulation Time Limits
Waste is accumulated not more than 90/180/270 JCCR 66262.34(d)]
3030010
Empty containers managed within one yur . CCR 66262.34(d)]
3030010
Universal waste accumulated .less than one year [CCR 66273.15(a)]
3030011
Used 'oil filters offsite within 180 (1 year <1 ton) [CCR 66266,130(c)(4)]
3.030004
Pb -acid batteries offsite within 180 (1 yr. < 1 ton) [CCR66266.81(a)(3)
3030002
Labeling/Marking
Containers are properly labeled [66262.34(f)]
3030007
Excluded recyclable materials marked properly [HSC 25143.9(a)]
3050005
Universal waste .container properly labeled (CCR 66273.34
3030008
Used oil filters marked "drained used oil filters" [CCR 66266.1301
3030004
Date written on spent lea&acid batteries [CCR 66266.81(a)(6 )(B)
3030003
"Used Oil" marked on all used oil tanks /containers CCR 66279.21(b)]
3030007
Tank marked with "haz waste" , contents, start date 66 62.34(f)l
3030007
Treatment Transport and Disposal/Other
Have permit/authorization to do treatment [HSC 25136.21
3040003
Waste sent with authorized transport (gen. eligible) CCR 66263.41
3050001
Waste disposed of to authorized point/ party [HSC 25189.5(a)]
3050002
Failed to properly handle appliance wastes rHSC 25212 a
Fire Protection [66262.34(d)(2)]
3030032
Print and sign in this box for receipt. of this, report. Signature does not imply agreement with findings only receipt of report.
INSPECTOR
POST INSPECTION INSTRUCTIONS:
Correct the violation(s) noted above by
Within 5 days of correcting all of the violations, sign and return a copy of this page to:
Bakersfield Fire Dept., Prevention Services, 2101 H St. Bakersfield, CA 93301
White - Business Conv YeAow, .Station Copy, ;
I;
Signature (that all violations have been corrected as noted)
Date
FD2171 (Rev.9 /14)
Pink- Prevention Services Copy
,FACILITY NAME
INSPECTION DATE
INSPECTION TIME
rnz
ADDRESS
PHONE NO.
NO OF EMPLOYEES
f; t4.
FACILITY CONTACT
BUSINESS ID NUMBER
Consent to Inspect Name /Title
IN
a =C` �. C9
':se.. k i ;.>. ,. '<.: ..} ,,,. < . f a.u, ■ , .. r f.. .t '. .. r ,..aS.Y �. ? f: .: Le K. i. :.'e. ,. ,�"s.a kj'.j
.'. ^e "�° Y.. ..ha � .. ' :JT, F> .:,, .>i yyy��. ry :.�yr�,wy.1�y,!/�� P' Il.•..:r„ �� r�`������ i�R ��. 'l ��' \ S )S L *S' �� 3�
,$`, .. Sect�Ql�..::�5 .> g:liS ireSS +Mtn 4 � , ,.. ,. a ,. ).. ... '�✓' 3'.. } 1M5. <
�y...,
>
❑ ROUTINE COMBINED ❑ JOINTAGENCY ❑ MULTI- AGENCY ❑ COMPLAINT ❑ .RE- INSPECTION
C V = omp iance OPERATION
C E R S
V= Violation; 1,11 Minor
Violation '
COMMENT
APPROPRIATE PERMIT ON HAND (BMC: 15.65.080)
3010001
BU. SINESS PLAN CONTACT INFORMATION ACCURATE (CCR: 2729.1)
1010008
VISIBLE ADDRESS (CFC: 505.1, BMC: 15.52 .020)
CORRECT OCCUPANCY (CBC: 401.)
VERIFICATION OF INVENTORY MATERIALS (CCR: 2729.3)
1010004
�g
t
VERIFICATION OF QUANTITIES (CCR: 2729.4)
1010006
VERIFICATION OF LOCATION (CCR: 2729:2)
w�
PROPER SEGREGATION OF MATERIAL (CFC: 2704.1)
VERIFICATION OF SDS AVAILABILITY (COR: 2729.2(3)(b))
VERIFICATION OF HAZ MAT TRAINING . (CCR: 2732)
1020002
VERIFICATION OF ABATEMENT SUPPLIES & PROCEDURES (CCR.-2731(c))
EMERGENCY PROCEDURES ADEQUATE (CCR: 2731)
1010010
Ai";
y
CONTAINERS PROPERLY LABELED (CCR: 66262.34(f), CFC: 2703.5)
3030007
HOUSEKEEPING (CFC: 304.1)
FIRE PROTECTION (CFC: 903 & 906)
3030032
SITE DIAGRAM ADEQUATE & ON HAND (CCR:.2729.2)
1010005
NY. HAZARDOUS WASTE ON SITE? ❑ YES ''- NO
Signature ofRecei��
Explain:
Inspector• r
POST INSPECTION INSTRUCTIONS:
Correct the violation(s) noted above by
• Within 5 days of correcting all of the violations, sign and return a copy of this page to: Signature (that all violations have been corrected'as noted)
Bakersfield Fire Dept., Prevention Services, 2101 H Street, California 93301
Date
White — Business Copy Yellow — Station Copy Pink — Prevention Services FD2155 (Rev 8H14)
Owner /Operator:
Facility:
Address: 5
R ZCa .
There were NO violations observed during this inspection.
�:. '�..:
_ .. :.. :n.r
?,
.... S..&:.T ... ,T..
. Sam k y:
a ,, c_ u ?•4. a _n.x n'?S k; "' "c ... 'i". k ',�. fx. .3 . .. ,. �, :. '.;H... � '.., o. mc"'k: ,". �.
,... kF' G T 2:. ,. verse•,, .W..,. "5s ,!a..�'. ._.% ..... <;+" b . x".'K.. ,.. .. b,i'3'3" ?:Y,...... i". ,.ry .:. :_
....... k '.. d" � 3 ay.7, .�.. .3✓ ..: i �` ..,...?'.kv. •k»ra Qy�' �S ,i", � , �. f ... ,.
,.xE,- 95i ..^ti.a ..3... °'3 rr..� .., e 4,e w.,..r �i•.. .r.., .,.. v . e [[����k;... .i_ . en' .. $„ !. a`.�` ... .'a �'
'.,,.. .1°. "E.,.. i. ,ou .y„ '� n._.:is. -•T..; .,7° i „., ..r.; t�a.�'*.
LEE—' Cr ;.
§ . -�,� �.a>,d.t:,M bx ..'�'j.
REQUIREMENT FOR CORRECTION OF.
a�. .1,�,. .,�, .Y,"h .. .. y .°�i�'
.o ... s r�i _ a."'+.
.., .m'
.. .. � ,K y. ,. m �.k°:'s` ke.,. i� .. V s ., ;4 Y?'” �v.•'�"• . "'i �3P.a
... . .. .,. ... �.., x.. ;. �. •�` -. '�.. .mot .: m.. �
101,111 r-$ ......3.* C?1 ... 5, _.... „w= :. •: _ '•'..'i§
`� ,.... .....x. >, �: 3.. .... -.��,� ...c. 5• , , �( �, .k��. f,.'�?w ,rts��.'• -4YrY _ . , ,y �.. .' 'c<k �<a §"t. ?Srs, 'sv,. 3am-»
�,.. �a+n �;a,,. `i �.?u. <..,��•'', n":. ��_ ,.� a.,.,..��.s�':;' L.,..... �—w u..a ��?�,'zi..++,: z�•'
Notice to Comply: Minor Violations were found during this inspection as: noted in the. following s
#
VIOLATION
Summa ry of Violations.
CORRECTION
The violations indicated in this inspection report must be corrected within 3Q days, unless
otherwise noted.
r f t.. CZ t . ro y 3t .x'741 a "'
Formal enforcement may be in for any'Violations noted, and for those. not. corrected in a '. .
timely manner.. This report does not rep resent.that there are no other violations at this facility.. A.
re- inspection may occur to determine compliance status.
KPR #RA46
Whi +p Ri icinrzc_c rnnv Yellow - Business Conv to be sent in after Return-to- Compliance Pink - Prevention Services Copy
SUMMARY OF VIOLATIONS
Item
REQUIREMENT FOR CORRECTION OF.
'DATE FOR
#
VIOLATION
VIOLATION
CORRECTION
s
r f t.. CZ t . ro y 3t .x'741 a "'
Inspectors
Received by:�...
Signature:) : :,
Phone: =
Print Name:
Date
Date:.'
KPR #RA46
Whi +p Ri icinrzc_c rnnv Yellow - Business Conv to be sent in after Return-to- Compliance Pink - Prevention Services Copy