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01/18/2013 15:24 1561 CHEVRON PAGE 02/05 ............... ................. SAN JOAQUIN COUNTY KuBVED ENvKRONmENTAL HEALTH DEPARTMENT 600 F_Main St,Stockton,CA 95202-3029 FEB 192013 Telephone:(209)469-3420 Fax:(209)468-3433 Web.,wWw.sjjov_qr ........ gc_bd LTH PER1,41T/SERVItES RETURN TO COMPLIANCE I CERTIFICATION Any_NENOR violations noted in the"Notice to Comply"in the attached Inspection Report must be corrected wift 30 days of receipt of t1lis ia*ection. This certification form must be submitted to the Environmental Health Department(EFID)address at the top of this form within 35 days of receipt Of the Inspection Report. All corrections to other violations noted in the attached inspection Report or Continuation Fox-M, or disputes to any Violations,are to be submitted using this certification and returned to EHD unless otherwise specified in the Inspection Report. Note: AR EHD staff time associated with faiUng to comply by the above noted"tes will be blued at the current hourly rate($122). For this certification to be Cts to the operator of thesite must include: • A statement documenting what correctivc actions were taken or will be taken for each violation • Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos veri5jing corrections • Operator's certification Inspectio n Date: jagorl 191_20t3 Lispected By: blikol _14F Facility Address: I I t)3 IhA 11) gTMt,!'OftVWPA 1D#: 0 POZ-0 00(2-o 4'02- I certify under penalty of law that: 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and I believe the information to be true,accurate,and complete: V rap \/ I -Photos erwork Statement 3. 1 am authorized to wbmit this certification on behalf of the Respondent. 4. 1 am aware that there are significant penalties for submitting false information,including the possibility of a fine and/or imprisonment for known violations. (HSC 25191) -?4VL1 Title,: Name: Date: i Ll L3 Signature: