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FROM : FREMONT SHELL PHONE NO. : 209 941 9743 Aug. 07 2006 04:15PM P4 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 Pett Welbor Avenuo, Std Floor, gtocZt n, CA. 9570M709 <br />'relephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.s' ov.or ehci <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 da rzs <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 />• Copies of sample results/manifests/training; records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: Z - ®t- inspected y: ; <br />CA z 9 o"tZ._ <br />Facility Address: -,2 �{ a_n� EPA ID#: (+ AD IS 6 <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. >;k <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 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: <br />Oicmatiire\%1K Date- C)ta <br />EHD 22-02-005 Rev 12-04 <br />