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�. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave.. Stockton. CA 95205 rR^A E1 VED <br /> Telephone: (209) 4688-3420 Fax: (209) 468-3433 Web:www.slcehd.co tIV' <br /> Complete and submit the "Return to Compliance Certification" form with theMlOogO 2014 <br /> corrections no later than 30 days from the date of the inspection. <br /> ENVIRONMENTAL HEALTH <br /> PERMITISERVICES <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 (EHD) address at the top of this form within 30 days of receipt of the <br /> Inspection Report. <br /> All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. <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 of $125. <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 /> • Operator's certification <br /> Inspection Date: May 2, 2014 Inspected By:_Robert Lopez_ <br /> Facility Address: t {SS`I S C1 E aG� Jc A ID#: Ca 11 - 00 YA(Ds 22 <br /> 1 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, <br /> ,accurate, and complete: <br /> -K <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 <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: J Title: <br /> Signature: y Date: - - �- <br />