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04/12/2017 8:49 AN FAX 2098236719 ONE STOP MARKET CHEVRON 1@0001/0003 <br /> San Joaquin County RECFIVED <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue,Stockton,California 95205-6= WR 2 2017 <br /> Telephone:(209)46&3420 Fax. (209)468-3433 Web:nw.aigw gEg&W' <br /> RETURN TO COMPLIANCE CERTIFI&OWMENTAL HEALTH <br /> DEPARTMENT <br /> Any Ml OR violations noted in the"Notice to Comply"in the attached Inspection Report must be ggMpgWd within 30-days.of <br /> receipt f this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address <br /> at the t of this form wit in 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All ions to gj r vi I lotions noted in the attached Inspection Report(IR)or Continuation Form,or disputes to any <br /> violatio 5, are to be subrr itted using this certification and returned to EHD within.. unless otherwise specified in the <br /> Inspecti)n Report. HSC 25185(c)(3) <br /> Note: All EHD staff ime associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> Fort is 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' w <br /> results/manifisttraining reoords/other appropriate paperwork,and/or photos verifying <br /> corrections I <br /> Operator's cern y cation <br /> Ins pe otion Date: December 05,2016 Inspected By: Elena Manzo <br /> Facill ty Address: 1161 W LOUISE AVE CER S ID; 10180661 <br /> 1 certify inder penalty <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"e,accurate.and complete: <br /> ..Photos-.--- V Paperwork_SUAement <br /> 3. 1 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 possibility of a fine <br /> and/or imprison ent for known violations. (HSC 25191) <br /> !y me: I W/F IRA &;I Title: <br /> Si)nature:__ rDate:— Id— ZI—Z 2, <br />