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77 ,� , ,� . E ;. <br /> San Joaquin' aunty <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www sigov or 1 hd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINA violations noted in the"Notice to Comply' in the attached Inspection Report must be corrected within 30 days_of <br /> receipt of this inspection 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 corre tans to other 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 ithin �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 include <br /> A statement documenting what corrective actions were taken or will be taken for each violation <br /> Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying <br /> corrections <br /> Inspection Date: January 20, 2015 Inspected By. <br /> Facility Address: 420 `,A) Kettle noun Ln, Loud EPA ID: <br /> I certify under penalty of law that <br /> 1. I 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 f Paperwork Statement <br /> 3. Lam 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: J Title: Zc° <7� 'i --- <br /> Signature: Date: <br /> ripe- <br /> 5 z' <br />