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SAN JOAQUIN COUNTY RECEIVED <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 1 6 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s6gov.org/ehd <br />ENVIRONMENTAL HEALTH <br />- .. <br />RETURN TO COMPLIANCE CERTIFICATION CEIVLD <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be b <br />corrected within 30 days of receipt of this inspection. This certification form must be submitted to th MENTAL <br />Environmental Health Department (EHD) address at the top of this form within 30 days of re ` 1B6W � ENT <br />RTMENT <br />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 <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br />unless otherwise specified in the 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 t0 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 <br />verifying corrections <br />• Operator's certification <br />Inspection Date: December 13, 2013 <br />Facility Address: 574 W Grant Line Road <br />I certify under penalty of law that: <br />Inspected By:Garrett Backus <br />EPA ID#: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the informationt be tr aCAE?, and complete: <br />I • [� eco-��-- � �� �S' �� �� <br />Photos ap rwork Statement <br />�j���y�1�C� <br />3. l at luthorized to submit this ceZcion <br />!Ibehalf of the espondent. <br />4. 1 am aware that there are significant penalties for submitting false information, including the <br />possibility of a fine and/or imprisonment for known violations. (HSC 251911) <br />Name:R_aA"<4,, _ Title: <br />Sianature: <br />EHD 22-02-005 Rev 04/19/12 <br />Date: / 14 1, <br />