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02/06/2017 02:22PM 2094773 CHEVRON STATION 1* PAGE 06/06 <br />San Joaquin County <br />Environmental Health Department <br />1888 East Hazelton Avenue, Stockton, California 95205-6232 <br />Tel®phone: (209) 468-3420 For: (209) 468-3433 Web: ww_wsioov.org/ehd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" In the attached Inspection Report must be corrected within 30 days of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address <br />at the top of this form within 30 days of receipt of the Inspection Report NSC 25404.1.2(c)(1) <br />All Corr lord to other violations noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br />violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the <br />Inspection Report. HSC 25185(c)(3) <br />Note: All EHD staff 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 recordslother appropriate paperwork, and/or photos verifying <br />corrections <br />Inspection Date: February 06, 2017 Inspected By: ELENA MAN20 <br />Facility Address: 3355 E HAMMER LN, STOCKT.ON CERS ID: 10182331 <br />I certify under penalty of law that: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br />and I believe the Information to be true, accurate, and complete: <br />Photos_Zpapennrork V Statement <br />3. lam 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 possibility of a fine <br />and/or imprisonment for known violations. (HSC 25191) <br />Name:_ a• mer le S R -f`+'I'e Tdle. VST- 7' <br />Signature-, _ ��3/ 17 <br />