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SAN JOAQUIN COUNTy <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, California 9` <br />tone: (209) 468-3420 Fax: (209) 468-3433 Web: wr <br />RECEIVED <br />APR 15 201 <br />32 <br />Y -or VIRONMENTAL HEALTH <br />DEPARTMENT <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached Insp laction Report must be <br />corrected within 30 clays of receipt of this inspection. This certification form must be submitted to the <br />Environmental Health Department (EHD) address at the top c this form wi -hin 30 days of receipt of the <br />Inspection Report, HSC 25404.1,2(c)(1) <br />All corrections to other violations noted in the attached Inspection Report (I'!R) or Continuation Form, or <br />disputes to any violations, are to be submitted using this certi1cation and r turned to EHD within 30 days <br />unless otherwise specified in the Inspection Report. HSC 25' 85(c)(3) <br />Note: All EHD staff time associated with failing to cc mply by th above noted dates will be <br />billed at the current hourly rate. <br />For this certification to be complete the operator of ttm e site must include: <br />• A statement documenting what corrective actions were t,iken or will b� taken for each violation <br />• Copies of sample results/manifests/training records/othe' appropriate !paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: _yl .1 t ��� L Inspected <br />Facility Address:! r'- 1 J .1._- UK (UU EI'A ID#: („! <br />I certify under pena y of law tha(vYi c �-{ <br />1. 1 have corrected the violations specified in the Inspec+:ion Report fr <br />inspection date. <br />2. 1 have personally examined the following documentat on submittec <br />EACH VIOLATION and I believe the information to bE true, accura <br />Aris Cacapit <br />71 <br />the above-mentioned <br />as proof of compliance FOR <br />and complete: <br />Photos Paperwo-k S atement <br />3. 1 am authorized to submit this certification on behalf o` the Respon ent. <br />4, 1 am aware that there are significant penalties for sub,nitting false ipformation, including the <br />possibili f a fine and/ori is-o�nm�ent for known viclations. (HS 25191) <br />Name. G Titl <br />nature: <br />EHD 22-02-005 Rev 04/19/12 <br />Date: <br />t 1 5'_ <br />