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Dec 30 2013 7:16PM HP Fax • page 2 <br /> SAN JOAQUIN COUNTY <br /> �I Y �® e <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 952 5-62 12 <br /> C $ ?Q13 <br /> Telephone:(209)46a-3420 Fax:(209)46&3433 Web: <br /> EN VI <br /> DEPARTMENT <br /> RETURN -0 COMPLIANCE CERTIFICAVION <br /> Any MINOR violations noted in the `Notice to Comply' in the attached Insr ectionReport m ist be <br /> _corrected within 30 days of receipt of this inspection. This certification for ri mut be submi ted to the <br /> Environmental Health Department (EHD)address at the top of this form w thin 30clays of ceipt of the <br /> Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other violations noted in the attached Inspection Report �A) o ntinuat n Form, or <br /> disputes to any violations, are to be submitted using this certification and rpturnm to EHD I qjhjMjgjM <br /> unless otherwise specified in the inspection Report. HSC 25185(c)(3) <br /> Note: All EHastaff time associated with failing to comply by th a ab a noted dates will be <br /> billed at the current hourly rate. <br /> For this certification to be complete the operator oft a site ust incl de: <br /> • A statement documenting what corrective actions were taken or will be takedfor each violation <br /> • Copies of sample results/maniiestshraining records/other appropriate papErwork, and r photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: 12 —`to - t \ Inspected 8): <br /> Facility Address:_MO (A+ht7y© 1T c EPA ID# 2 <br /> 1 certify,under penalty of law,thet: <br /> 1. 1 have corrected the violations specified in the Inspection Report fr)m the above-m( ntioned <br /> inspection date. <br /> 2. 1 have personally examined-the following documentation submitted as p o f of com fiance FOR <br /> EACH VIOLATION and I pelieve the information to be true, accura e, ar d complete <br /> PhotosPaperwork S1 atern al it <br /> I <br /> 3. li am;authorized to submit this certification on behalf of the Respon ent <br /> 4. 1 am aware that there are significant penalties for submitting false ii iforffn, inclu ling the, <br /> possibility of fine and/or imprisonment for known violations. (HS 25 J <br /> I <br /> Name: Title: <br /> Signat e: <br /> r <br /> i <br /> .. EHD22.02005 Rav M12 <br /> i <br />