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11/13/2009 19:46 20972 30 PAGE 02/03 <br /> San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California 952056232 <br /> rekephone:(209)468-3420 Fax:(209)468-3433 Web:www sigov Oralehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be correct�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 HSC 25404.1.2(c)(1) <br /> All corrections jaD#Wr vlolations 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 records/other appropriate paperwork, and/or photos verifying <br /> corrections <br /> Inspection Date: _ August 28 2014 inspected By: JAMIE DE LA ROSA <br /> Facility Address: 14000 E Highway 88 Lockeford EPA ID: (,lql-Z/D 0,12 / ' --7 <br /> I certify under penalty of law that. ' <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. I have personally examined the folk wing documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information to Wtrue, accurate, a complete: <br /> --4—/Photo. 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 /> and/or imprisonment for known violations. (HSC 25191) i ! <br /> Name: . S :U C 115 ritie: �t7ViM) l a✓1C2 /,) ,dt T <br /> Signature: _ Date: <br />