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Feb. 19. 2014 3: 21PM HAMILTON SERVICES No, 1180 P. 3 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazeiton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209)468-3420,Fax;(209)468-3433 Web:www.s' ov.or nF.2�.CEIVEES <br /> FF9 19 201,4 <br /> RETURN TO COMPLIANCE CERTIFICATIVIRGINENTAL <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Repo &T&u ePARTMENT <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 (IR) 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 EMD 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: c1 -1q' I Inspected By:Jeffrey Wong <br /> Facility Address: X11'7.3 Al A0 EPA ID#: DDD /6 9 7 77 <br /> 1 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 Paperwork_,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 of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: Title: <br /> Signature, �;!-G NA) �0 oc_6 Date: <br /> EHD 22-02.005 Rev 04/19/12 <br />