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UNDERGRO <br /> ND STORAGE TANK <br /> STATEMENT OF UNDERSTANDIING AND COMPLIANCE FORM <br /> (P.a• + a +l SAN JOAQUIN Environmental Health Department <br /> Every undetend aroundnd Is storage atank (UST) hclliry must submit a om"I'me atetamem Indicating that the owner or <br /> understands and is In comPitence with all Applicabl UST mgkdmmeme. Atopy of this eemp�jeW loan moat be submitted <br /> via either Ua California Environmental Reporting SyeUS (Cquirem nts.an A copy <br /> alent this unlined program reporting Porter Within 30 days of: 1) in IMtallaaon of a UST; or 2) a clunga In owner Of operator Man UST, sppIIcsbI6O <br /> [tafomia <br /> Code M Regutaaons, Title 20, DMslon d, Chapter 1e, Section 271 ala).) <br /> T'"ea""°" niarwimeLonan RETURN TO COMPLIANCE CERTIFICATION <br /> ❑ cwa. aD..w,np ❑ Gupra Oparaor <br /> I. FACILITY INFOR6UTION Any MINOR violations rated in the •Notice to Comply' in the attached Inspection Report must be rsaac+ed vnNn 30 dans of <br /> Subeu Hamr (aama ar Irrrw °� earneu CERs ,o / l recelpt of this Inspection. This certification form must be submitted to the Environmental Health Department (EHD) address at <br /> r,r • to l & t gra bottom of this form within 30 days of receipt of the Inspection Report HSC 25404.1.2(c)(1) <br /> + + t1kCGn 4P COM As corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br /> II. OWNER / OPERATOR INFORMATION 7 violations, are to be subrrided using this certification and returned to EHD within 30 days unless otherwise specified in the <br /> ReYlbnati¢blkvbgreW ala•p Twa(e Inspection Report. HSC 251e5(c)(3) <br /> 13Door �aPw.w <br /> fur Oiniri0p1r�;°f N" Phwea Note: All EHD staff time associated with falling to comply by the above noted dates will be billed <br /> c Y\um1003 Loq- 8z 3.yQ41 at the current hourly rate. <br /> 1151 Wcer Sim Wceaa <br /> clic 513ro For this certification to be complete, the operator of the she must Include: <br /> III. CERTIFICATION BY OWNERI OPERATOR OF UNDERSTANDING AND COMPLIANCE A statement documenting what corrective actions were taken or will be taken for each violation <br /> 1 hereby center that I understand Me orad • Copies of sample resuesfmandestsltraining recordslolher appropriate paperwork, and/or photos verifying corrections <br /> aground storage tank requirements of Health " Set* Code, Division 20, Operators certification <br /> Chapter C7, CW'f ml& Code M RegvlagOru: TWO 23, Division 2, Chapter to; and any applicable local underground *tango <br /> tank ordinance* and that the f2cl0ty Identified above la In compliance with all aPPticable vocal underg Bund storage <br /> rank <br /> regwnma`ts. Ins ection Date: December 15, 2020 <br /> usr Wil i;; a�wvr• Inspected By: PAUL NSO <br /> P <br /> 1 <br /> . i / /i tz- r 5_ z,.i „ Facility Address: 1151W LOUISE AVE, MANTECA CERS ID: 10180661 <br /> I cenity under penally M law that <br /> 1 . I have corrected the violations specified in the Inspection Report from gra abovea boned inspection date. <br /> 2. 1 have personally examined the fu5owing documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the Information to be We, accurate, and complete: <br /> _Photos _Paperwork Stalemtmt <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am VW2M that there an rignficant ponahleo for submitting false information, including the possibthty of a fine <br /> arKV" knpdswn t ton kr violations. (HSC 25191) <br /> Name: C , \\\bTole:— �V�P..�f <br /> i <br /> Signature: 4�4 „ �A�i,rsy�o7 Date:— <br /> Dabwab,aa, <br /> I <br /> I <br /> I <br /> 3 <br />