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COMPLIANCE INFO_2019
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2300 - Underground Storage Tank Program
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PR0231532
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COMPLIANCE INFO_2019
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Last modified
3/3/2021 12:05:19 PM
Creation date
1/7/2019 4:05:24 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
2019
RECORD_ID
PR0231532
PE
2351
FACILITY_ID
FA0000185
FACILITY_NAME
CITY GAS & LIQUOR
STREET_NUMBER
16470
STREET_NAME
CAMBRIDGE
STREET_TYPE
ST
City
LATHROP
Zip
95330
APN
19643032
CURRENT_STATUS
01
SITE_LOCATION
16470 CAMBRIDGE ST
P_LOCATION
07
P_DISTRICT
003
QC Status
Approved
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SJGOV\kblackwell
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EHD - Public
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SAN ,J O A O U I Environmental Health Department <br /> CQU Wry <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address <br /> the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other violations noted in the attached Inspection Report (IR)or Continuation Form, or disputes to any <br /> violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification to be complete, the operator of the site must include: <br /> A statement documenting what corrective actions were taken or will be taken for each violation <br /> Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br /> Operator's certification <br /> Inspection Date: January 03, 2019 Inspected By: ELENA MANZO <br /> Facility Address: 16470 CAMBRIDGE ST, LATHROP CERS ID: 0 <br /> 1 certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine <br /> and/or imprisonment for known violations. (HSC 25191) <br /> Name: Title: <br /> Signature: Date: <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />
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