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San Joaquin County <br />Environmental Health Department <br />11168 East Hazelton Avenue, Stockton, California95205-6232 <br />Teleph e: (209) 468-3420 Fax: (209) 468-3433 Web: www.sagov.org/ehd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in te"Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br />c <br />receipt of this inspection. This t1ification form must be submitted to the Environmental Health Department(EHD) address <br />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 EHDwithin 30 days unless otherwise specified in the <br />Inspection Report. HSC 25185(c (3) <br />Note: All EHD staff ti a associated with failing to comply by the above noted dates will be <br />billed at the curren hourly rate. <br />For this certification o be complete, the operator of the site must include: <br />A statement documentin what corrective actions were taken or will be taken for each violation <br />Copies of sample result manifeststtraining records/other appropriate paperwork, and/or photos verifying correction: <br />Inspection Date: Novem <br />19, 201 <br />Facility Address: _4z_35 CORD RD, CLEMENTS <br />Inspected By <br />EPA ID. <br />ARIb VELOJO <br />I certify under penalty of law that: <br />1. 1 have corrected the violc, tions specified in the Inspection Report from the above-mentioned inspection date. <br />2. 1 have personally exams ied the following documentation submitted as proof of compliance FOR EACH VIOLATI <br />I believe the information o be true, accurate, and complete: <br />Photos Paperwork Statement <br />I am authorized to subm't this certification on behalf of the Respondent. <br />4. 1 am aware that there arsignificant penalties for submitting false information, including the possibility of a fine and/ <br />imprisonment for known solations. (HSC 25191) <br />Name: <br />Title: <br />Signature: I Date: <br />