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001/30/2010 10:52 12093341873 FLAGCITV CHEVRON PAGE 01/04 <br />SAN JOAQUIN COUNTY <br />F_Nv{120NMt:N1'AL HEALTF{ DEPARTMENT <br />600 E. Main St., Stockton, CA 95202-3029 <br />Telephone: (209) 463-3420 F'ax; (209) 468,3433 Web: www.sjgov.oX/ehd <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 (EI -ID) address at the top of this form within 35 days of receipt of the <br />Inspection Report. <br />All corrections to other violations noted in the attached Inspection Report or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 30- clays <br />unless otherwise specified in the Inspection Report, <br />Note: All EHD staff' time associated with hailing to comply by the above rioted dates will be billed at <br />the current hourly rate (S105). <br />For this certification t0 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 />t� <br />• Operator's certification <br />Inspection Date: <br />Vroo <br />Facility Address:--6`lAV�� <br />I certify under penalty of law that: <br />Inspe�dr2010 <br />EPA <br />I have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. 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. I am authorized to submit this certification on behalf of the Respondent. <br />4. I am aware that there are signi�Ccant penalties for submitting false information., including the <br />possibility of a Eine and/or imprisonment for known violations. (1 -[SC 25191) <br />^ <br />Siv_nature: �A-,*40 <br />^- , - --- i n fV7 <br />Date:'5 <br />