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• I ( I O SAN JOAQUIN COUNTY ) ENVIRONMENTAL HEALTH DEPARTMENT I 600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd RETURN TO COMPLIANCE CERTIFICATION Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be corrected within 30 days of receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address at the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.12(c)(1) All corrections to other violations noted in the attached Inspection Report(IR)or Continuation Form,or disputes to any violations,are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the Inspection Report. HSC 25185(c)(3) Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at the current hourly rate. For this certification to be complete the operator of the site must include: • A statement documenting what corrective actions were taken or will be taken for each violation • Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections • Operators certification Inspection Date: `a1 ' 0%(3 Inspected By:Stacy Rivera f Facility Address: lnOS ZIJ, t)V MLK EPAID#: I certify under penalty of law that: 1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. i 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and I believe the information to be true,accurate,and complete: Photos Paperwork Statement 3. 1 am authorized to submit this certification on behalf of the Respondent. 4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine and/or imprisonment for known violations. (HSC 25191) 1 Name: - J r. (- Title: Signature: Date: ldz?%1 T EHD 22-02-005 Rev 09/11