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10!13!2613 18:53 2093399097 SANBORI PAGE 01/03 f�Li <br />RE EIVEL) <br />SAN JOAQUIN COUNTY OCT 14 26`3 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 SAN JOAOUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: w6 si�oy,org/ehd ENVIRONMENTAL <br />- __ -- HEALTH DEPARTMENT <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any UNOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />WE N -ted within 3Q 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 Compete 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/man ifestsitraining records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: SEP 15, 2013 <br />Facility Address:1190 S. CHEROKEE LN <br />I certify under penalty of law that-, <br />Inspected By:Aris Cacapit <br />FPA ID#: CAL000337354 <br />1, I have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2- 1 have personally examined the fallowing documentation submitted as proof of compliance FOR <br />EACH VIOLATION and 1 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 />.-, .. <br />Si <br />EHd 22.02-405 RCv 0411902 <br />Date: h <br />