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03/08/2017 11:37AN FAX 2098236719 ONE STOP MARKET CHEVRON Q0003/0006 <br /> San Joaquin county REOPEIVED <br /> Environmental Health Department <br /> 11611 East Hazelton Avenue,Stodow,CWnbn*962OV432 10 A R 0 8 2017 <br /> Tis e"(209)468,3420 Fax.,(209)468-3433 Weir WMAWM2Wj"h <br /> ENVIRONMENTAL HEALTH <br /> An RETURN TO COMPLIANCE CERTIFICATION DEPARTMENT <br /> -MLIQR-violations no in the"Notice to COMW in the attached Inspection Report must be P2anadLm*b1QAW of <br /> Pt of this inspection. <br /> Of 4 <br /> a a of is 'this c0MG4ftr1 form must be submitted to the Environmental Health Department(EMD)address <br /> t e top Of this fwn within 30 days of receipt of the Inspection Report HSC 25404.1.2(c)(1) <br /> A 4 <br /> j <br /> L 192W-Yi�,noted in the attached Inspection Report(IR)Or Continuation Form.or disputes to any <br /> via ions.are to be submitted using this certificatlon and returned to EMD <br /> Ins g 'on ReporL HSC 25185(c)(3) W-ft-U-ShM unless otherwise specified in the <br /> tes <br /> No e., All END-staff time associated with failing to COMPlY bY the above noted da will <br /> be <br /> billed at the current hourly rate, <br /> Fa"this Certification to be complete, the o Of the$ite must include: <br /> A statement documenting what corrective actions were taken or wall be taken for each violation <br /> COPift Of sample resuft/manftstsftining re=rds/other appropriate paperwork verifying <br /> corrections ,and/Or PhOtos ver ng <br /> In DeCtionDate: December 05. 2016 Ins ted By: ELENA MANZO <br /> Fa pity Address: 1151W LOUISE AVE. MAN- CA CER S ID. 10180661 <br /> cerl fy under penaky of law that: <br /> 1 have corrected the vMa#OnS SPeclfletl in the Inspection ROPW from the above-mentioned in on date. <br /> I have personally examined the foliovi4ng documentation su mitted as <br /> and I believe the information to be true,accurate,and complete; <br /> ---�__Photos Paper work J <br /> X -Statement <br /> 1 am authorized to submit this cerIffilcation on behalf of the Respondent <br /> 4 1-am aware that there are significant Penalties for submitting false information,including the <br /> OndflOr Imprisonment for known violations. (HSC 25191} Possibility of a fine <br /> lamw.A —Tdje—A. <br /> 4;ignatWe- Date- <br /> r <br />