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San Joaquin County <br />Environmental Health Department ---g- <br />1868 <br />1868 East Hazelton Avenue, Stockton, California 95205-8232 I ( , 6 N p,N <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www s_ioov orolehd ` <br />OCT 2p '1 <br />RETURN TO COMPLIANCE CERTIFICATION CNVIRONM <br />EIvrAL <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected3�cnir <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address <br />the top of this form within 30 days of receipt of the 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 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/manifesWilraining records/other appropriate paperwork, and/or photos verifying corrections <br />Inspection Date: <br />September 21; 2015 <br />Inspected By: <br />HAZA SAILED <br />Facility Address: <br />1050 W BROOKSIDE RD, <br />STOCKfON EPA ID: <br />C, AD °r6l 4r,%0-2 3 <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 />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 possibility of a fine <br />imprisonment for known violations. (HSC 25191) <br />Title: ��y �� DN N��7� 1 Ft tk2 E t t <br />a ^ <br />Ste` <br />Date: f 1 r 3 1 -- <br />