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-tit L <br /> San Joaquin County <br /> ��.- I 0 L-�- > Environmental Health Department <br /> S al <br /> l� 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> ( <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MI ations noted in the"Notice to Comply" in the attached Inspection Report must be corrected 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 within 30 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 usi g this certification and returned to EHD within 30 days unless otherwise specified in the <br /> Inspection Report. HSC 25185(c)(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/ anifests/training records/other appropriate paperwork, and/or photos verifying corrections <br /> Inspection Date: August 9, 2015 Inspected By: STACY RIVERA <br /> Facility Address: 440W DIR MARTIN LUTHER KING JR BLVD 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 inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> I believe the information to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3. 1 am authorized to submill 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 known v olations. (HSC1 25191) I . <br /> Name: i1 e f QN1 h Title: IM R C�e Y <br /> Signature: Date: ICAQ�!c <br /> a <br /> - Fac—a•,�ru <br />