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` Y <br /> San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton , California 95205-6232 <br /> Te lepho!}e: ( 209 } 468 -3x20 fax: (209 ) 468-3433 Web: yvwry siaov org/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the " Notice to Comply' in the attached Inspection Report must be gorre d 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 carr c ions to oth r viola ions 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 34 da 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 corrections <br /> Inspection Date: November 23 , 2015 inspected By : STAG Y PI `JL= RA <br /> Facility Address : 1990 N PIOOOLI RD , S - (- OCKTON EPA 111v <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 /> - � <br /> Photos !'L� . Paperwork i� 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. ( NSC 25191 ) � �,+ ; <br /> Name : I .i f41xot� Tile: t ! ` z.g � <br /> Date: l� 3 <br /> Signature: a — - -- <br />