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99/23/2014 16:27 20946E 3 SJC EHD UNIT 3 PAGE 66106 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, Califomia 95205-6232 0 C T 01 2014 <br />Telephone, (209) 488-3420 Fax: (209) 488-3433 Web; www.sjgov,or lcLehd <br />ENVIRONMENTAL HEALTH <br />DEA P <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br />Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the <br />Inspection Report_ MSC 25404.1.2(c)(1) <br />All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to any violations, are to be submittedusing this certification and returned to EHD wi hit n 30 days <br />unless; otherwise specified in the Inspection Report.. NSC 2-5185(10)(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 <br />verifying corrections <br />• Operator's certification <br />Inspection Date: June 12 <br />2014 <br />Inspected By: Elena Manzo <br />Facility Address: 1399 E Yosemite Avenue EPA ID#:- <br />I certify under penalty of law that: <br />1, 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos L�apwwork Statement <br />3. 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 <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />Name: n Title:_ <br />nature: <br />EH O 22-02-005 Rev oar 9112 <br />