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RECEIVED <br /> San Joaquin County APR 2 7 2017 <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 ENVIRONMENTALHEALTIi <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 Web:www.sjgov.org/ehd PERMIT/SEWCES <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be corrected within 0 days of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHDaddress <br /> at 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 using 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 The <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 verifying <br /> corrections <br /> Operator's certification <br /> November 02, 2016 Inspected By. <br /> Robert Lopez <br /> Inspection Date: p <br /> Facility Address: 1102 W FREMONT ST CERS ID: 10187731 <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection da e. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH V OLATION <br /> and I believe the information to be true, accurate, and complete: <br /> _Photos_,_Paperwork Statement ir�(?Ak.5c,>> 0 , 11-S <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. 7t0--,-z' �o �l <br /> 4. I am 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: - Title: <br /> Signature: Date: z <br /> 9171 9690 0935 0131 1294 79 <br />