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San Joaquin County K� � �� <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California95205-6232 MAR 2 2 2016 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web.www.s6Pov.orQ/ehd <br /> ENVIRONMENTAL HEALTH <br /> RETURN TO COMPLIANCE CERTIFICATION PERMIT/SERVICES <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 withln30 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 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 correction: <br /> Inspection Date: March 14. 2016 Inspected By: ARIS VLLO50 <br /> Facility Address: , (;CUFF AVL LODI EPA ID,0,4b9g"S&7.?i3O <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 Y_ Paperwork_,V_— 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 andl <br /> imprisonment for known violations. (HSC25191) <br /> Name: - 12—J•G/-77' Title: <br /> Signat e: - Date: 2l 6 <br />