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Apr21 1509:18a P.1 <br /> ._ San Joaquin County V IAV"414 <br /> d 1fj/L Environmental Health Department T.)TrEGE! �/ L 1868 East Hazelton Avenue, Stockton. Califomia95205-6232 <br /> Telephone.(209)468-3420 Fax: (209)468-3433 Web:www.sigov.orglehd fl/ r S <br /> APR 2 T 2015 L�;5; <br /> NVIRONMENTA>TURN TO COMPLIANCE CERTIFICATION <br /> Any NTII�OWQEQAFnA'0;d is 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 /> 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/manifests/training recordslother appropriate paperwork, and/or photos verifying correction: <br /> Inspection Date: =.:• .:)_. - Inspected By: <br /> Facility Address: S Z 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 dale. <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 /> Photos Paperwork Statement <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 andl <br /> imprisonment for known violations./(HSC 225191) <br /> Name: <br /> Signature: e �aYt z L Date: �1 " -7 —15 <br /> Ci 0 S <br />