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COMPLIANCE INFO_2019
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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2300 - Underground Storage Tank Program
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PR0231911
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COMPLIANCE INFO_2019
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Entry Properties
Last modified
11/20/2024 9:21:33 AM
Creation date
9/15/2020 2:19:15 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
2019
RECORD_ID
PR0231911
PE
2361
FACILITY_ID
FA0000540
FACILITY_NAME
COUNTRYSIDE LIQUORS & GAS
STREET_NUMBER
14971
Direction
N
STREET_NAME
STATE ROUTE 88
City
LODI
Zip
95240
APN
06316025
CURRENT_STATUS
01
SITE_LOCATION
14971 N HWY 88
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
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SJGOV\kblackwell
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EHD - Public
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SJ N ...1JOAQUIN <br /> Environmental 'Health Department <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the " Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address <br /> at the top of this form within 30 days of receipt of the Inspection Report, HSC 25404. 1 . 2(c)( 1 ) <br /> All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form , or disputes to any <br /> violations, are to be submitted using this certification and retumed to EHD within 30 days unless otherwise specified in the <br /> Inspection Report, HSC 25185(c)( 3) <br /> Note: All EHD 'staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this 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 results/manifests/training records/other appropriate paperwork, and/or photos verifying <br /> corrections <br /> Operator's certification <br /> Inspection Date : March 26 , 2019 Inspected By : ZUNA BARKER <br /> Facility Address : 14971 N HWY 88 , LODI CERS We 10180623 <br /> 1 certify under penalty of law that: <br /> 1 . I 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 true, accurate , and complete: <br /> Photos 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 possibility of a fine <br /> and/or imprisonment for known violations. ( c 5191 ) <br /> Name : Title : V - <br /> 1 101 <br /> Signature : _ Date : <br /> 1868 E . Hazelton Avenue i Stockton , California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd. com <br />
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