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Oct 21 12 04:44p Lower Sacramento Chevron 2099540582 P.1 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue,Stockton, California 95245-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web.w-WW.§jgp—v.QV--ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any LAINOR 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 Deparhmint(EHD)address at the top of this form within 30 days of receipt of the <br /> Report. HS 2 2 '(1) the d <br /> n n, <br /> po 'c <br /> n5otherwise <br /> 0"i e other <br /> C' M�"'noted <br /> n r violations <br /> miReport.using this <br /> r <br /> Io Rr rti HSC <br /> 5 to <br /> Inspection <br /> 7ee any b <br /> inspection Report(I R) or Continuation Form,or <br /> disputes <br /> ttvw e be <br /> certification and returned to EHD within 30 dans <br /> 0 <br /> s I <br /> un ss ot y �ffed in Me In C 25185(cX3) <br /> Note: <br /> 11 1 s ff time soclate it failing <br /> g I <br /> Ali <br /> E 4D as in to comply by the above noted dates vAll be <br /> t b this <br /> at Me current <br /> houd mile. <br /> �ei ti tsubmitted <br /> late <br /> For his ce ica ion o bie coeons e ethe opemtor of the site must include: <br /> • A statement documentin what rrective were taken or will betaken for each violation <br /> • Copies of sample resultXanifestsAraining records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: October 15, 2012 Inspected By:Garrett Backus <br /> Facility Address:8660 Lower Sacramento Rd EPA ID#: <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 /> 2. 1 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_Zpaperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent <br /> 4. lam aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations.LZH6191) <br /> Name: Title: <br /> Signature: Date: <br /> EM 22-02-005 Rev OVI S12 <br /> REGL <br /> OCT 2 2 2012 <br /> GANJOAQWCOMY <br /> EW.6�W <br /> HEALTHDEPAF(I?KrNr <br />