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le Mar, 1914 04:44p Shell 1-5 _T 209 390963 P.1 To' 70W SAN JOAQUIN COUNTY : 14 '"C9VED ENVIRONMENTAL HEALTH DEPARTMENT E 6()0 East Main street, Stockton, CA 95202-3029 Telephone: x - MMY MAR IS 2014 phone: (209) 468-3420 P v. (209) 469-343 3 Web. -SM0__V-_0W�C_hd ENVIRONMENTAL HEALTH RETURN TO CIANCE CERTIFICATION DEPARTMENT Any _MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address at the top of this form within 35 days of receipt of the inspection Report. All corrections to other violations noted in tho attached Inspection Report (IR) or Continuation Form, or disputes to any violations, are to be submitted using this certification and returned to EHD within 30 dAYs unless otherwise specified in the Inspection 1ieport- Note: All ERD staff time associated with filing to comply by the above noted dates will be Wed at the current hourly rate ($122). For this certification to be complete the operator of the site must include: • A statement documenting what correptive actions were taken or will be taken for each violation • Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections • Operator's certification Inspection Date: 0 3/F/ --2,,O I /+ - - I I Facility Address: --717 UL. _je_4r^ C44- cl 510 I certify under penalty of law that: Inspected EPA ID #: C�A L 0 00 �; 0 I. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and I believe the information to be true, accurate, and complete: Photos -paperwork Statement 3. 1 am authorized to submit this certifIcation on behalf of the Respondent 4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine and/or imprisonment for known violations. (HSC 25191) E14D 22-02-005 Rev 08/10 Title:_ O-uj Date: