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08/07/2009 09:29 12093341873 FLAGCITV CHEVRON PAGE 01/04 <br />f <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 f=ast Main Street, Stockton, CA 952023029 qUG <br />Te/options: (209) 4683420 Fax. (209) 468-3433 Web: www. si_ oy,org/Ehd 0 7 20og <br />,d <br />AL <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected within 30 days of receipt of this inspection, This certification form must be submitted to the <br />Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the <br />Inspection Report. <br />All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br />unless otherwise specified in the Inspection Report. <br />(Vote: All EHD staff time associated with falling to comply by the above noted dates will be <br />billed at the current hourly rate. <br />For this certification t© 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 <br />verifying corrections <br />Operator's certification <br />Inspection Date: FSI 7/ 0 9 _ _ _ Inspected By:_ _1 Q e d <br />(Facility Address: 4"RI C042i o.< Ye EPA ID#: <br />dad -1' <br />I certify under penalty of law that: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection dale. <br />2_ 1 have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos X Paperwork Statement <br />3_ 1 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 the <br />possibility of a fine and/or imprisonment for known violations. (FISC 25191) <br />Name: K j vv, -o fs k a,T • v' a et d r " Title: 0,4-ro - <br />Signature: <br />EHD 37.07.006 Rev 08108 <br />Date: W/ 7 / v <br />