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RECEIvEDF- <br /> SAN <br /> JOAQUIN COUNTY JUN o 4 2014 <br /> ENVIRONMENTAL HEALTH DEPARTMENT ENVIRONMENTAL HEALTH <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209)468-3420 Fax;(209)468-3433 Web:www.siaov.or"PARTMENT <br /> RET JRN TO COMPLIANCE CERTIFICATION <br /> Any MINO=hin <br /> a ions no d in the `'Notice to Comply" `n the attached Inspection Report must be <br /> corrected 3 daysf 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 5404.1.2(c)(1) <br /> All corrections to Wher 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 otherwisepecifi in the Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD tall tirr a associated with failing to comply by the above noted dates will be <br /> billed at the curt ent hourly rate. <br /> For this ceocica Ion to be complete the operator of the site must include: <br /> • A statement ume ting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: Inspected By: -Th <br /> Facility Address: yGEPA ID#: <br /> I certify under penalty of law that: <br /> 1. i have cor ected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally xamined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete: <br /> Photos Paperwork _Statement <br /> 3. 1 am authc rized to submit this certification on behalf of the Respondent. <br /> 4, 1 am away 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: dt"j0(Liv— <br /> Signature: 14 Date: <br /> EHD 22-02-00S Rev 04119,'12 <br /> £-d dL0 Zl b6 t0 un- <br />