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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:www,s ov.o <br /> RETURN T4 COMPLIANCE CERT <br /> Any MI^ NpR violations noted in the " j�j�'�r�aN <br /> receipt of this inspection. This the "cation fo Comply be submitted Comply" m the attached Inspection Report must be corrected within 30 claysof <br /> the top of this form within 30 days of receipt of the Inspection Report, HS <br /> ed t. the Environmental Health Department(EHD) address, <br /> All corrections to other violations noted in the attached Inspection Re C 25404.1.2(c)(1) <br /> violations, are to be submitted using this certification and returns <br /> Inspection Report, port(IR) or Continuation Form, or disputes to any <br /> p HSC 25185(c)(3) d to END withi— 0 datirs unless otherwise specified in the <br /> Note: All EHD staff time associated with failing to CO <br /> billed at the Current hourly rate, mplY by the above noted dates will be <br /> Far this certification to be complete, the operator of t <br /> he 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 ver <br /> Inspection Date: Au ust 08, 2016 afying corrections <br /> inspected By: VICKI MCCARTNEY <br /> Facility Address: 116 Roth Rd, I_athro <br /> I certify under penalty of law that: EPA !D: <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 /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. I 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: —Title.- <br /> Signature: <br /> itle:Signature: Date: <br />