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p ' 'D Uj <br /> San Joaquin County MAR 0 7 201� � <br /> Environmental Health Department <br /> V 1868 East Hazelton Avenue, Stockton, California 9 , <br /> I ��(� Telephone:(209)468-3420 Fax:(209)468-3433 Web: TVyNIT <br /> � jGlJ�7� <br /> ETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be torr w 30 d of <br /> receipt of this inspKhOn. This certification form must be submitted to the Environmental Health Department(EHD)address <br /> at the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All correpbo5 to Dther 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 EHD within 3Q a_s unless otherwise specked in the <br /> Inspection Report MSC 25185(c)(3) <br /> Note: All EHO 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 sampie results/manifests/training recordslother appropriate paperwork, and/or photos Verifying <br /> corrections <br /> inspection Date: Janua y 19, 2016 Inspected By: CINDY Vo <br /> Facility Address: 1302 W FREMONT ST STOCKTON EPA ID: <br /> 1 certify under penalty of law that: <br /> 1. t have corrected the violations specified in the Inspection Report from the above-mentioned inspectlon date? <br /> 2. I 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 certifcatlon 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 /> e; <br /> JNA <br /> Name: Titlr J <br /> Signature: Date: <br /> vl .. � <br />