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MAY-11-2017 11:19 From: To:4683433 Page:116 <br /> w San Joaquin County I! fj <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue,Stockton,California 95205-6232 MAY 1 1 2017 <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web:www.slaov.orn/ehd <br /> I <br /> RETURN TO COMPLIANCE CERTIFICATION VIRONMENTAL HEALTH <br /> PFRARTMENT <br /> Any MINOR violations noted in the"Notice to CTompV'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 at <br /> the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections 10,other violations noted in the attached Inspection Report(IR)or Continuation Form,or disputes to any <br /> violations,are to hp submitted using this certification and returned to EHD within 30 dews 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 certifiication 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: Aril 05, 2017 Inspected By: AARON HANG <br /> Facility Address: 800 W MOSSDALE AVF, LATHROP EPA ID: <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 /> and I believe the information to be true,accurate,and complete. <br /> Photos Paperwork Statement <br /> i <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. irnc� G�t�' C " � Title:� 0;101, A,(,�p <br /> Signatur 5�4Date: S 9 <br /> "I, Ffev.t Q s I,) CD'C� t��o sk c`ts�r rtlr r C�'a'-fir t -e7� f y <br /> �4�• ��,;v;e /�1 r �, / `ems / �y���/�) // /� <br /> /t CVu� C�(J /`t 4 r.R_ a..< {c ACC �� -�Od( PC1A!v_W0'1 40'-'P t F14:11— 6r���.. �b'L <br /> i JJ�.� <br /> NNW <br /> 1,,,,t <br /> ����t� <br />