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kx. <br />f e_t-int u,l�� <br />��? O i lr� San Joaquin County <br />) Environmental Health Department <br />1866 East Hazelton Avenue, Stockton, California 95205-6232 <br />TelepNione: (209) 465-3420 Fax: (2.09) 46£3-3433 Web: www.s'gov.ora/ehd <br />v.ora/ehd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 des of <br />receipt of this inspection. This &rlification form mist be submitted to the Environmental Health Department (EHD) address <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 violation noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br />violations, are to be submitted Lsing 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 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 documentirjg what corrective actions were taken or will be taken for each violation <br />Copies of sample result$/manifests/training records/other appropriate paperwork, and/or photos verifying <br />corrections <br />Inspection Date: JWILIMjy 12, 2016 <br />Inspected By: S In(W RIVLRA <br />Facility Address: 833 L [-IG1 fl -1 1 ST, STOCK ON EPA ID: <br />I certify under penalty of law tha <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br />and I believe the informadion to be true, accurate, and complete: <br />Photos `Paperwork _Statement <br />3. 1 am authorized to submil: this certification on behalf of the Respondent. <br />4. 1 am aware that there aro significant penalties for submitting false information, including the possibility of a fine <br />and/or imprisonment fork own violations. (HSC 25191) <br />Name: V. I N \ C t;G NS <br />Signature: QJ V, -- <br />Title: MRN��Gv- DELA <br />UPF CZAT o NS <br />Date: F -r, -6a Lit--P-Y i t , 2-0((.o <br />RECEIVED <br />FEB 1 1 2016 <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />