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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />Tele hone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s' ov.oI-ICCE'VE <br />D, <br />FE6 18 2014 <br />RE URN TO COMPLIANCE CERTIFICATION <br />ENVtRDNMENIFAL HEALTH <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Re�;*KAO'OCES <br />corrected within 30 da sl of receipt of this inspection. This certification form must be submitted to the <br />Environmental Health D partment (EHD) address at the top of this form within 30 days of receipt of the <br />Inspection Report. HSCI25404.1.2(c)(1) <br />All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to any violation , are to be submitted using this certification and returned to EHD within 30 days <br />unless otherwise specifi4d 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 cuent hourly rate. <br />For this certific tion to be complete the operator of the site must include: <br />• A statement docum nting what corrective actions were taken or will be taken for each violation <br />• Copies of sample re ults/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certificatiI n <br />Inspection Date: 110 <br />Facility Address: F) 33 c 8-+- 5roEe'r <br />I certify under penaltX of law that: <br />Inspected By: Stacy Rivera <br />EPA ID#: C)Wqt2oyo Zo"7 <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. 1 have personallyxamined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />K Photos K Paperwork Statement <br />3. 1 am authorized t submit this certification on behalf of the Respondent. <br />4. 1 am aware that th re are significant penalties for submitting false information, including the <br />possibility of a finq and/or imprisonment for known violations. (HSC 25191) <br />Name: �()Ff-1 t.::1XC-` <br />Sianature: <br />EHD 22-02-005 Rev 04/19/12 <br />Title: <br />Date: <br />