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• San Joaquin County • �. y r r <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, Califomia95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sagov.org/ehd DEC 2 9 2015 <br /> RETURN TO COMPLIANCE CERTIFICATIO VIRONMENTAL <br /> ADTAACKIT <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 /> 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 EHDwithin 30 days unless otherwise specified in the <br /> Inspection Report. HSC 25165(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/manifestsftraining records/other appropriate paperwork, and/or photos verifying correction! <br /> Inspection Date: Inspected By <br /> Facility Address: 4,40 `rr1i EPA ID: <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. 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. I am aware that there are significant penalties for submitting false information, including the possibility of a fine and/ <br /> imprisonment for known violations. (HSC 25191) <br /> Name: Y-1-CI i' ci ^,0,56f-) Title: �iad r ear �Gt��p )_ <br /> _ q <br /> Signature: <57 Date: eL�� t,� Z 1 ao/5� <br />