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FROM : MARIGOLDSHELL PHONE NO. : 209 952 4862 Sep. 01 2016 10:52AM P2 <br /> -ROM MnRIGOLDSHELL P"OhE NC. : 209 952 4862 22 2015 02= 1QPM P5 <br /> Sart Joaquin County 6, _ 24Ld V�►' . <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(2:09)468-34201:4x:(209)468-3433 Web:wv/ ,kg9y.org/ehd SSP � 1 l�t6 <br /> "ONA Mo <br /> RETURN TO COMPLIANCE CERTIFICATION � <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be corrected. i 3nda of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address: <br /> the top of this fo;m within 30 days of receipt of the Inspootion Report. HSC 25404.1.2(c)(1) <br /> All t:nrrections tuber violatjgM 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 EHD wilhin30 days unless otherwise specified in the <br /> Inspection Report. NSG 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 resuita/nzanifests/training records/other appropriate paperwork, and/or photos verifying corrections <br /> Inspection Date: August 19. 2016 Inspected By: VICKI MCCARTNEY - <br /> Facility Address: 6131 PACIFIC AVE. STOCKTON EPA 1D: <br /> 1 certify under penalty of law that, <br /> 1. l have corrected tilt violations specified in the ln5pech6n Report from the above-mentioned inspection date, <br /> 2_ l have personally examined the following documentation submitted as proof of complianoe FOR EACH VIOLATION <br /> and I believe the information to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3. l am authorized to submit this certification on tenalf of the Respondent. <br /> 4_ lam 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: uer l`laic` l flakt— Title: � .a a-c-L-, <br /> Date: U <br /> Sigrtatut <br />