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03/11/2014 09:56 2093344684 <br /> 45838 P.001 /003 <br /> SAN JCOUNTY RECEIV <br /> ENVIRONMENTALAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue,Stockton,California 95205-6232 <br /> Telephone-,(209)468-3420 Fax.(209)468-3433 Web:www.sieov era(ehd <br /> �AaR 1 1 2014 <br /> ENVIRONMEN)AL <br /> RETURN TO COMPLIANCE CERTIFICATION HEALTHOEPARTM <br /> Any MINOR violations noted in the`Notice to Comply"in the attached Inspection Report must be <br /> corrected within 30 days of receipt of this inspection. This certification form must be submitted to the ! <br /> E vironmental Health Department(EHD)address at the top of this form within 30 days of receipt of the <br /> bspection Report. HSC 25404.1.2(c)(1) <br /> i <br /> AL corrections to other violations noted in the attached Inspection Report(IR)or Continuation Form,or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. HSC 25185(c)(3) j <br /> Vote: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> I <br /> I <br /> or this certification t0 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 /> :e?les of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> O„--rator's certification <br /> 1 ;;;,ection Date: 3.-1a-(± Inspected By:. I I P-4 IF3 <br /> Facii:.v Address: 101 w •W'(,Lw an Q/I EPA ID#: CAI (20Q <br /> ! cor!ify under penalty of law that: <br /> ^. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> spection date. <br /> ! :^.ave personally examined the following documentation submitted as proof of compliance FOR <br /> _ACH VIOLATION and I believe the inforrpation to be true, accurate, and complete: j <br /> V/ <br /> Photos Paperwork {//'Statement I <br /> r..m authorized to submit this certification on behalf of the Respondent. <br /> am aware that there are significant penalties for submitting false information, including the <br /> sibility a fine and/or imprisonment <br /> for known violations. ,(,HSC 25191) <br /> \a; ;e: Pl1tU�ilf �N Title: JG(/ <br /> lure: 1 Date: <br /> P.zv 04119112 <br /> i <br />