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SAN JOAQUIN COUNTY [����'��® <br /> ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED <br /> 1868 East Hazelton Avenue, Stockton,California 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siaov.org/ehd JUL 17 2014 <br /> ENVIKUNMEN"ktttLTH <br /> PERMIT/SERVICES <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. HSC 25404.1.2(c)(1) <br /> All corrections to other violations noted in the attached Inspection Report(1R)or Continuation Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the 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/manifests/training records/other appropriate paperwork, andlor photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: i125Inspected By:)) <br /> y: <br /> 4 <br /> Facility Address:, !( !j�ttb ( � 7)r EPA ID#: �,��f L iy f 3 <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. l have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I bell ve the informati to be true, accurate, and complete: <br /> Photos Paperwork <br /> 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 <br /> possibility iiof a fine an <br /> d/or imprisonment for known violations. (HSC 25191) <br /> Name: t (, V Title:�2�E'�'� <br /> Signature: Date: <br /> EHD 22-02-005 Rev 04/19112 <br />