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San Joaquin County RECEIVEnEnvironmental Health Department <br /> 168 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Teleph ne: (209) 468-3420 Fax: (209) 468-3433 Web:www.sjgov.org/ehd OCT 0 2 2015 <br /> RETURN TO COMPLIANCE CERTIFICATION ENPJERMMENTALCEALTH <br /> ES <br /> Any MINOR violations noted int e "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection. This certification 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 us ng 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 tirne associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification �o be complete, the operator of the site must include: <br /> A statement documentingwhat corrective actions were taken or will be taken for each violation <br /> Copies of sample resultsnanifests/training records/other appropriate paperwork, and/or photos verifying corrections <br /> Inspection Date: September 01, 2015 Inspected By: STACY RIVERA <br /> Facility Address: 5161 W ELEVENTH ST, TRACY EPA ID: <br /> I certify under penalty of law that: <br /> 1. I have corrected the viola ons specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. I have personally examin d the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> I believe the infor ation t be true, accurate, and complete: <br /> Photos Paperwork_Statement <br /> 3. 1 am authorized t submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine and/ <br /> imprisonment fornown vi lations. (HSC 25191) <br /> Name: ���r�� «�� Title: 5ffHar / <br /> Signature: Date: /c t ro <br /> i <br />