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SAN JOAQUIN COUNTY RECEIVED ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.Hazelton Ave., Stockton,CA 95205-6232 OCT 2 9 2013 Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sj og v.or EWROfHMENT4L HF_4 RETURN TO COMPLIANCE CERTIFICATION Any MINOR violations no ed in the "Notice to Comply"in the attached Inspection Report must be corrected within 30 days o receipt of this inspection. This,certification form must be submitted to the Environmental Health Department(EHD) address at the top of this form within 35 days of receipt of the Inspection Report. All corrections to other violations noted in the attached Inspection Report or Continuation Form,or disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the Inspection Report. Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at the current hourly rate (S 125). For this certificate n to be complete the operator of the site must include: • A statement documenting what corrective actions were taken or will be taken for each violation • Copies of sampler sults/manifests/training records/other appropriate paperwork, and/or photos verifying corrections • Operator's certification Inspection Date: I o 2 13 Inspected By: T G, •�.y �('1/`0� vN Facility Address: W 11"- Sf `srp�LEPA ID#: C L 0 0 0 'U 4 `f'8$' I certify under penalty f law that: 1. I have corrected th violations specified in the Inspection Report from the above-mentioned inspection date. 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and I believe the information to be true, acc urate, and complete: Photos ,/Paperwork 3. I am authorized to ubmit this certification on behalf of the Respondent. 4. lam aware that there are significant penalties for submitting false information, including the possibility of a fine and/or imprisonment for known violations. (HSC 25191) Name: .e , Title: l,r a„A,',A a Signature: Date: 16 /2013 EHD 2.2-02-005 RPv 10-07