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02/19/2016 WED 11: 12 FAX ��'�{ I E fdJ002/010 <br /> • ' ® l � <br /> SAN JOAOIIIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT FEB 19 2014 <br /> 1868 East Hazelton Avenue, Stockton, California 95205.6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:wwwAnovv.mg(phd <br /> ENVIRONMENTAL HEALTH <br /> RETURN TO COMPLIANCE CERTIFICATION <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 farm 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 falling to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this Certification t0 be completethe 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/manlfests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Data: 1115/Z6,14 Inspected By:Stacy Rivera <br /> Facility Address:/055.5 Sbdeyion 5{. � EPA ID#: CAL 0000IMP1S <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 -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: a /�� Title; <br /> Si natu Date: <br /> EHD 22.02-DOS Ray 04110/12 <br />