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10/09/2014 10:45 2098582435 ELME; PAGE 01/01 <br /> .cuo�4o3 WU EHD UNi l � PAGE 02/02 <br /> SAN JOAQUIN COUNTY � ' `"-t `7 <br /> ED <br /> ENVIRONMENTAL HEALTH DrnPARTMFNT <br /> 1668 East Hazelton Avenue, Stockton, California 95205-6292 0 C T 0 9 2014 <br /> telephone;(209)468.8420 Fax:(209)468-3433 Wed:y✓M.slgov otglehd <br /> HEALTH <br /> RETURN TO COMPLIANCE CERTIFICATION DEPARTMENT <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be <br /> orrected 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(0)(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(0)(3) <br /> Note: All EHD staff time assoGlated with falling to comply by the above noted gates 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 resuRs/man'rfestsdraining recordslother appropriate paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: � Aa 2� I �0 t{ Inspected By: U— <br /> D 22 <br /> Facility Address: 1 r c� t� t EPA ID#: o f <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 1 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 <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name; �zq c-1� t kb Title: <br /> Signature! ' <br /> �i Date: � -j <br /> en d Rx-oz-oaa ev��can e++z <br />