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Jul 21y,1�512:02p DELL • 20 46-0677 p.1 <br /> San Jc aquin County <br /> UUU <br /> Environmental Health Department <br /> 1868 East Hazelton Avent e, Stockton, California 95205 6232 <br /> Telephone:(209)468-3420 Fax, (209)468-3433 Web:www siaov.om/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the 'Notice to Comply" in t ie,attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection. This certification form must be bbmitted to the Environmental Health Department(EHD)address; <br /> the top of this form within 30 days of receipt of the InspecionReport, HSC 25404.1.2(c)(1) <br /> All corrections to other violations noted in the attached Inpection Report(IR)or Continuation Form, or disputes to any <br /> violations,are to be submitted using this certification andreturned to EHD within 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 actiont were taken or will be taken for each violation <br /> Copies of sample resultslmanifestsltraining recoidstother appropriate paperwork, and/or photos verifying corrections <br /> Inspection Date: June 19, 2315 . Inspected By: CINDY VO <br /> Facility Address. 1861E MAIN ST, STOCK.ON EPA ID: (kVW3X%:� <br /> 1 certify under penalty of law that: <br /> I <br /> t. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personally examined he 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 th s 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 2u5191) <br /> Name: Ptell'AaAaeZ Title: 111 At/ _ <br /> Signature: t Date: I ► /o1/S� <br /> RECEIVEIG <br /> JUL 2 2 2015 <br /> SN <br /> VIRONMENTP:l.. <br /> '„�r,T„^��roTnrriT <br />