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01126/2012 11:41 1561 CHEVRON PAGE 01/05 <br /> • <br /> 3 n <br /> SAW JOA4u1N COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 a <br /> i! Telephone;(209)466-3420 Fax:(209)468-3433 Web:wwovc�rand a <br /> (F <br /> it <br /> aal <br /> I iF 1( 1`iAL. .F <br /> RETURN TO COMPLIANCE CERTIFICA <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 /> I! <br /> i; 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 dans <br /> unless otherwise specified in the Inspection Report. <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 /> F®r this certification to be com lete the operator of the site must include: <br /> it . 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 /> i! Oaerator's certification <br /> a <br /> Inspection Date: w '1 ' , Inspected By: <br /> Facility Address, I a l44 EPA I : <br /> I certify under penalty of law that: <br /> i <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> j; inspection date. <br /> i <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 /> ii <br /> '! Photos Paperwork Statement <br /> I! <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 <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: O� WakIts Title: ! `i� <br /> Signature. Date: - <br /> _. <br /> it <br /> EHo 22-02-0o6 Rev to/os <br />