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05/04/2015 16: 50 20936993 WINE COUNTRY £.ION PAGE 05 <br /> San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.siaov.ora/ehd <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 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 actions were taken or will be taken for each violation <br /> Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br /> Inspection Date: h`i>ir I, :�t,i.�> Inspected By: F=i_ ExA fdU\W-r <br /> Facility Address: ;;c9cii,n EPA ID: <br /> I certify under penalty of law that: <br /> 1. I 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 VIOLATION <br /> believe the information to be true, accurate, and complete: <br /> Photos X Paperwork X 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 possibility of a fine and! <br /> imprisonment for known violations. (HSC 25191) <br /> Name:stephen Boyd Title: Rg, Gasoline Env. Comp Mgr. <br /> Signature: Date. 5/22/2015 <br /> RECEIVEL <br /> MAY 222015 <br /> ENVIRONMENTAL. <br /> IJC61TU nrQe QTIACMT <br />