Laserfiche WebLink
Dec 28 06 10: 36a Wilson Way Chevron 2099422306 p. 2 <br /> SAN JOAQUIN COUNTY <br /> ENV[RONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3'd Floor,Stockton,CA 95202-2708 <br /> Takphene:(209)468-3420 Fax.(209)468-3433 Web:wwwAgov.ore%hd <br /> RETURNTO 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 35 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 60 days <br /> unless otherwise specified in the IR. <br /> For this certification t0 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 /> e Copies of sample results/manifestsltraining records/other appropriate paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: !1 I b o Inspected By: 10uA G <br /> Facility Address: ^' '`'"S"`s EPA ID#: (Pfl_000 30&o32- <br /> Sjbck%9 Ok q Stas <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I 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—/—Paperwork ✓ Statement <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 the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: Title: r%A-jAC 1-- <br /> Signature: Date: i v` ob <br />