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San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazefton Avenue,Stockton, Califomia95205-8232 <br /> Telephone:(209)4M3420 Feu:(209)46"33 Web:www.sluov.oro/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the'Notice to Comply'in the attached Inspection Report must be ogaected 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 within30 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 EHDwithin 30 days unless otherwise specified in the <br /> Inspection Report HSC 251850(3) <br /> Note: All EHD staff date associated with failing to cornpiy 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 conective actions were taken or will betaken for each violation <br /> Copies of sample resutfs/manifeststralning recordstother appropriate paperwork, and/or photos verifying correction: <br /> i <br /> Inspection Date: October 30 2015 Inspected By: I i iR r <br /> Facility Address: 10101 1NDIJSTRIA1. . S1OCMTON EPA ID: CIPIL00" eA <br /> I certify under penalty of law that <br /> I. I have corrected the violations specified In the Inspection Report from the above-mentioned inspection dote <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH%AOLAT1 <br /> I believe the information to be true,accurate,and complete. <br /> PhotosXPape6wrk 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 knownvwlatl ns. (HSC25191) <br /> Name: �' 0%4� Title �n, 7` .✓.9g P�— <br /> Signature: zld 4Z Date i �� <br />