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09118'2013 14:56 12653341873 FLAGCITV CHEVRON PAGE 81/05 <br />STAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />8 3424 Fair; (269) 468-3433 Web. LA.s' ov.org/ehd <br />SEP 1 S 2093 <br />Telephone. (2Q9) -5 - <br />_T <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected within 30 -days of receipt of this inspection. This certification form must be submitted to the <br />Environmental Health Department (F -HD) address at the top of this form within 30 days of receipt of the <br />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 <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br />unless otherwise specified in the Inspection Report. HSC 25185(c)(3) <br />Note: All EHD staf 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 <br />verifying corrections <br />* Operator's certification <br />Inspection Date: August 20, 2013 — inspected By:Aris Cacapit <br />Facility Address: 6421 Capitol Ave. Lodi, EPA ID#: CAL000346851 <br />I certify under penalty of law that: <br />1, 1 have corrected the violations specified in the Inspection Report, from the above-mentioned <br />inspection date. <br />I have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />--Photos Paperwork -Statement <br />3. 1 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 <br />possibility of a fine and/or imprisonment for known violations. (I-ISC 2.5191) <br />Name, OIALti�—S f.iSA,11---Title: <br />Signature: <br />EH6 22-02-D08 Rev W19/12 <br />11= <br />Date: 9 1'�,/�ol� <br />