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SAN JOQUIN <br /> UNTY <br /> ENVIRONM NTAALHEALTHODEPARTMENT 1 ECEIV <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 E� <br /> Telephone:(209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd DEC G O 2013 <br /> RETURN TO COMPLIANCE CERTIFICATION Ealrrf°NMENNAL <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 /> Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the <br /> 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 <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) <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 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 /> • Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: ((/Iv <br /> /�/3, Inspected By:Jeffrey Wong <br /> T A <br /> Facility Address: 2k � G�} <br /> 730 / wr^e, EPA ID#: Oq-909?7/78' <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete: <br /> Photos V"' 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 <br /> possibility <br /> yoof"a fine and/or imprisonment for known violations. -(HS/C 25191) <br /> Name: C v1 H �Y(ti4mt Title: / P� /Ic�it'�l <br /> Signature: Date: / 3 O <br /> EHD 22-02-005 Rev 04/19/12 <br />