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• San Joaquin County <br /> J Environmental Health Department <br /> NoQ- <br /> MWY� 12-0" 868 East Hazelton Avenue, Stockton, Califomia 95206-5232 <br /> Telephone:(209)4683420 Fax:(209)4fi8-9433 Web.,www si�4av or9lehd to <br /> RETURN TO COMPLIANCE CERTIFICATION APR 3 0 2015 <br /> Any MINOR violations noted in the Notice to Comply"in the attached Inspection Report must be <br /> receipt of this rnsp <br /> action- This certification form must be submitted to the Environmental Health Department T <br /> at the top of this form within 30 days of receipt of the inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to Qther dQjMtjpns 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 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 inctude: <br /> A statement documenting what corrective actions were taken or will be taken for each violation <br /> Copies of sample results/manifests/training recordslather appropriate paperwork, and/or photos verifying <br /> corrections <br /> Inspection Date: October 15, 2014 Inspected By: STACY RIVERA <br /> + <br /> Facility Address: 8288 S EL DORADO ST, FRENCH CAMP EPA ID: 1.j* �Q0S57C) L/,3 g <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 A_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 <br /> and/or imprisonment for known violations. (HSC 25191) <br /> Name: �• iS �1 <br /> Title. <br /> Date: <br /> Signature: ` l t 1 L <br />