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03/11/2014 09:56 2093344684 #5838 P.001 /003 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT 0 <br /> 1868 East Hazelton Avenue,Stockton,Calffomia 95205-6232 RECEIVED <br /> Telephone:(209)468-3420 Fax. (209)468-3433 Web:www.sigov oro/ehd MAR 11 1' 2014 <br /> ENVIRONME <br /> P RE L <br /> RETURN TO COMPLIANCE CERTIFICATION HFA,L7H0EPAfflM <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be <br /> corrected within 30 days of 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 /> 1.,�spection Report. HSC 25404.1.2(c)(1) <br /> X".corrections to other 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 retumed to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. HSC 25185(c)(3) <br /> V ote: All EHD staff time associated With failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> or this certification to be complete the operator of the site must include: <br /> • A statement documenting what corrective actions were taken or will be taken for each violation <br /> '.,-.,)Ies of sample resuits/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> Op,arator's certification <br /> ".7 <br /> J 7z;;�ectlon Date: Inspected <br /> Facii.1-.-y. Address: I W -Kk!WM an EPA ID#: CA- <br /> 1 cc.-t'fy under penalty of law that; <br /> I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> .;-.spection date. <br /> z have personally examined the following documentation submitted as proof of compliance FOR <br /> :SACH VIOLATION and I believe the info ation to be true, accurate, and complete; <br /> Photos 7 Paperwork V-100Statement <br /> -m authorized to submit this certification on behalf of the Respondent. <br /> am aware that there are significant penalties for submitting false information, including the <br /> ,-,SslbiI1ty4q a fine and/or imprisonment for known violations, (HSC 25191) <br /> \ ,.. e: Tide, Ift/ <br /> t u re: <br /> u re: Date: <br /> E: -.;f:5 Rev 04h ei/i 2 <br />