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v � 2016 r <br /> County E14VIRt�iMVEN i�L HE4L rH <br /> Sala Joaquin Coin f'ER <br /> Environmental' Health Department MiT/3ERv7CEg <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(208)4168-3420 Fax_(209)468-3493 Web:www.sigov.4rq/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the Notice to Comply" in the attached Inspection Report must be correctQ.i within 30 dgy§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 cc rrgct ons to other violaligns noted in the attached Inspection Report(IR)or Continuation Form, or disputes to any <br /> violations,are to be submitted using this certification and retumed to EHD withL30 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 recordslother appropriate paperwork. and/or photos verifying corrections <br /> Inspection Date: August 08, 201E Inspected By: VICKI MCCARTNEY <br /> Facility Address: 116 Roth Rd, Lathrop , EPA ID: M-00095.LOVI <br /> I 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 VIOLATION <br /> and I believe the information to be true, accurate, and complete: <br /> —Photos Paperwork Statement <br /> 1 I 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 <br /> andlor imprlsonment For known violations. HSC 25191) <br /> i <br /> Name; Qi� Title: <br /> Signature: Date. (/ <br />