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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:i sjgov-p[g/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINQR violations noted in the"Notice to Comply" in the attached Inspection Report must be resected within 30lo�Cs of <br /> receipt of this inspection. This certification farm 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 25404.12(c)(1) <br /> All corrections to other violpU rens 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 wil in 30 days unless otherwise specified in the <br /> Inspection Report, HSC 25185(c)(3) <br /> NOW 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/manifesWtraining records/other appropriate paperwork, and/or photos verifying corrections <br /> Inspection Date: August 08, 201$ Inspected By: rVICKI MCCARTNEY <br /> Facility Address: 110 Roth Rd, Lathrop EPA ID, d: �©��237.11 / C5 <br /> I certify under penalty of iaw that: <br /> 1- l have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personalty examined the following documentation submitted as proof of compliance FOR EACH%nOLATION <br /> and I believe the infoambon to be true, accurate, and complete: <br /> Photos Paperwork_k 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 <br /> and/or imprisonment for known violations. HSC 25191) <br /> Name.- <br /> 9 Q� Tifle: <br /> Si nature; Date: <br /> REED E D' <br /> OCT 14 2016 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />