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San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California95205-6232 MAY 06 2016 <br /> Telephone:(209) 468-3420 Fax: (209)468-3433 Web:www sioov ora/ehd <br /> Firth <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in 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 EHOwithin 30 days unless otherwise specified in the <br /> inspection Report. HSC 25185(e)(3) y. <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 orwill be taken for each violation <br /> Copies of sample resultstmanifestsltraining records/other appropriate paperwork,and/or photos verifying corrections <br /> Inspection Date: Inspected By <br /> Facility Address: EPA ID <br /> certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATIO <br /> I believe the information to be true, accurate, and complete: <br /> Photos Paperwork tatement <br /> 3. 1 am authorized to submit this Certification on b e Respondent. <br /> 4. 1 am aware that there are significant penalties forsubmitting false information, including the possibility of a fine andv <br /> imprisonment for known violations. (HSC25191) <br /> Name: �Sit ryDcTS" N3.6 LAN, Title. nt�1i <br /> Signature: i «3c}Qe — Date: <br /> Z eLE01, 91, 90AG" <br />