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San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue,Stockton, Califomia95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siaov.oro/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR 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 /> the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> i <br /> All corrections 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 EHDwithin 30 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/manifestsrtraining recordslother appropriate paperwork, and/or photos verifying correction: <br /> Inspection Date d,ruai y iii, 'l_016 Inspected By: ARI '/1: t :)3U <br /> Facility Address:-1 19001-- LOCKE_ RU L./JCKLFr i(a1 EPA ID. <br /> I <br /> I certify under penalty of iaw that: <br /> i <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 /> I believe the information to be true,accurate,and complete: <br /> V PhotosPaperwork_–Zstatement <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 and! <br /> imprisonment for known violations. (HSC 25191)nn <br /> Name: Kick: nou erf Title: �H� nirerll-o <br /> Signature:=% uu Date: y�2 g�Zol� <br /> i <br /> 1 <br /> i <br />