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• San Joaquin County • `t jt�-/��(' <br /> P L l Environmental Health Department <br /> q, <br /> 1�C�f ZXT36 �4 `� 868 East Hazelton Avenue, Stockton, California 9520"232 y <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web: v -/ehd t:vj L. <br /> RETURN TO COMPLIANCE CERTIFICATION JUN 12 2015 <br /> An MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be te <br /> Y d wi days of d <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address <br /> at the tap of this form within 30 days of receipt of the Inspection Report HSC 25404.1.2(c)(1) <br /> All corrections tomer viol ns 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 EHI)within 3Q days unless otherwise specified in the <br /> inspection Report. HSG 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 resufts/manifests/training records/other appropriate paperwork,and/or photos verifying <br /> corrections <br /> Inspection Date: October 15, 2014 inspected By, STACY RIVERA <br /> Facility Address: 8288S ELDORADO ST FRENCH CAMP EPA ID:CA 00 0550 yz 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 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. (H$025191) <br /> Name: �Q� S �1 <br /> Title: <br /> Signature: Date: l <br />