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02/06/2017 02:22PM 2094773690 CHEVRON STATION 170 PAGE 06/06 <br />x. <br />F-1 <br />San Joaquin County <br />Environmental Health Department F F' <br />J. 0 2, 101 <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />Telephone, (209) 468-3420 Fax: (209) 4683433 Web: MM,9jgov.org/ehd <br />E N V IR 0 N M, T P, L HEA LT H <br />Any MINOR violations noted in the "Notice to Comply' in the attached Inspection Report must be corrected within Ig da 0 <br />. ya f <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address <br />at 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 EH 0 within 30 days unless otherwise specified in the <br />Inspection Report. HSC 25185(c)(3) <br />Note: All EMD 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 <br />corrections <br />Inspection Date: February 06, 2017 Inspected By: ELENA MANZO <br />Facility Address: 3355 E HAMMER LN, STOCKTON CERS ID- 10182331 <br />I 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 jimnisonment for known violations. (HSC 25191) <br />NOtf <br />Name: cii-v<'Im r—,qvj hl pc Title:: Co *A e W f. t- Ce - <br />a-9 Ialt- <br />Signature: Date: 15 [0 3 7,0 t-1 <br />