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SAN TAL HEN COUNTY <br /> o ENVIRONMENTAL HEALTH DEPARTMENT �Clihes/6_I;`$,143o <br /> 600 East Main Street,Stockton, CA 95202-3029 H.liV3H"1ViN3-V1N06MN3 <br /> Telephone:(209)468-3420 Fax.,(209)468-3433 Web:www.sigov.org/ehd <br /> EIR 0 i AM <br /> IT <br /> RETURN TO COMPLIANCE CERTIFICATION (1AI33 <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(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 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, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: `41t,o11 3 Inspected By:Stacy Rivera <br /> Facility Address: /3147 S, AAa&,TC-r-) 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 <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--X—PaperworkStatement <br /> 3. lam authorized to submit this certification on behalf of the Respondent. <br /> 4. lam 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: Date: <br /> EHD 22-02-005 Rev 09/11 <br />