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1900 - Hazardous Materials Program
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PR0536640
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COMPLIANCE INFO
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Last modified
3/27/2019 1:46:59 PM
Creation date
1/17/2019 11:30:44 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
1900 - Hazardous Materials Program
File Section
COMPLIANCE INFO
RECORD_ID
PR0536640
PE
1921
FACILITY_ID
FA0000395
FACILITY_NAME
S-MART #655
STREET_NUMBER
530
Direction
W
STREET_NAME
LODI
STREET_TYPE
AVE
City
LODI
Zip
95241
APN
03319037
CURRENT_STATUS
01
SITE_LOCATION
530 W LODI AVE
P_LOCATION
02
P_DISTRICT
004
QC Status
Approved
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EHD - Public
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r SANJOAHIN Environmental Health Department <br /> CQUN1 Y <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any M N R violations noted in the " Notice to Comply , in the attached Inspection Report must borr wi h ' <br /> n 30 days o <br /> receipt of this inspection , This certification form must be submitted to the Environmental Health popartmont (CHH) address f <br /> at the top of this form within 30 days of receipt of the Inspectlon Roport, MSC 25404 . 1 .2(c) ( 1 ) <br /> All rroretions othr vial 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 EH () unless otherwise specified in the <br /> w' in <br /> Inspoctlon Report, HSC 25185(c) (3) -- �V,€ <br /> Note : All EHD staff time associated with failing to carr, ply 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 rosults/manifests/training records/othe <br /> corroctiong r apprapriat0 paperwork, and/or photos verifying <br /> Operator's certification <br /> Inspection Date ; Januar 15 , 2019 <br /> Inspected By: JAMIE LIMA <br /> Facility Address : 530 W LODI AVE , LODI <br /> CERS ID : _ 7Q1 $0567 _ <br /> I cortlfy under ponalty of law that; <br /> 1 . t have corrected tho violations spocified in the Inspectlon Report from the abov7omenlirection date, <br /> 2 . I have personally examined the following documentation submltt as proof of EACH VIOLATIONand I believe tho Information to be true, accurate , and comple <br /> f'hotps � paporwork <br /> 3, I am Authorized to submit this certification on behalf of the Respondent, <br /> 4. I am aware that there are signifiCant penalties for submitting false information . Including tho possibility of a fine <br /> and/or imprisonment for known violations, (HSC 25191 ) (^ <br /> Name ; f 1 / Title ; ct -1- Cl <br /> Signature ; <br /> ESE % ( ED <br /> FEB 0 01 2019 <br /> ENVIRONMENTAL HE_ ALTFI <br /> 186817 . Hazelton Avonue I Stocl<ton , California 952051 T 20946$.34201 F 209454,0138 1 www, sjcehd , com <br /> 6 / 4 d ££ £89 602 « 6109199526 J6WgL90 ' ZL 90 - Z0 - 6602 <br />
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