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■ <br /> ■ <br /> :. Environmental W # ent <br /> S AN A 0: A U. <br /> .A: .:.. •y�r: ��rr"yI VE® <br /> V. w:., =` r, t� :Kr .!vi-..:here; EC <br /> ENVIRONMENT <br /> RETURN TO COMPLIANCE CERTIFICATION PERIIIRSERV)CESITH <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. HSC 25404.1.2(e)(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. MSC 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 /> Operator's certification <br /> Inspection Date: December 14, 2018 Inspected By: JAMIE LIMA <br /> Facility Address. 12470 Locke Rd, Lockeford CERS ID: 10422565 <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 /> and I believe the information to be true,accurate, and complete: <br /> Photos K 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) <br /> Name: S1e.0 e It Q r 15 I c "i Title: ('�U/4 e- <br /> Signature: ,/ -� i pate: 2- <br /> f <br /> 1858 E. Hazeiton Avenue I Stockton,California 95205 i T 209 4683420 1 F 209 464-0138 1 www,sjcehd,com <br /> Received Time Dec. 21. 2018 3 : 02PM No, 4509 <br />