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12/2,2/2008 08:1,7 FAQ%^825772,2 biANTECA SHELL RECEr/ED 1 <br /> 0 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT' <br /> 600 East Main Street,StocWn,CA 95202-5029 DEC 2.2 2008 <br /> Telephone.(209)468-3420 Fax:(209)4683433 Web:www. gov orQ/ehd <br /> SAN�R�AQ, Co Nry <br /> 0 M/iPARTMENT <br /> RETURN TO: COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in.the"Notice to Comply"in the attached Inspection Report must be <br /> wi,,,,*30 days of receipt of this inspection. This certification form must be submitted..to..the. <br /> Envirdamental Health Department(EHD)address at the top of this form within 35 days of receipt o€they <br /> Inspection Report. <br /> All corrections IQ other vie a ' noted in the attached Inspection Report(IR)or Continuation Form,or. <br /> disgutes.to.any violations,are to be submitted using this certification and returned to EHD:M., jWn 30 days <br /> unle86.0therw1Se specified in the Inspection Report. <br /> Note: All EHD staff time associated with failing to comply by the above noted:dates will,be billed at- <br /> the curren.t hourly rate. <br /> For this Certification to be GoMplete 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/hidaing records/other appropriate paperwork,an#drphotos <br /> verifying corrections <br /> Operator's certification <br /> Date: 0 Inspected By: . . ... <br /> . Inspection . <br /> FacE`ty Address: ON f < EP #: <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. 1 have personally examined the following documentation submitted as proof of compliance;FO.R.. <br /> t., <br /> EACH VIOLATION and I believe the information to be true,accurate and complete:- <br /> Z <br /> Photos L . Paperwork Statement <br /> 3. I 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 25,191) <br /> Name: Y �,1Tette: at <br /> Date: /7_ <br /> EFM 22,02-005.Rev 11/07 ""; <br />