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a4.; 0 (` San Joaquin county -D <br /> Environmental Health Department =--- �". <br /> 868 East Hazelton Avenue,Stockton, California 95205-6232 <br /> I'V et: <br /> lrel ores:(208)468-3420 :(209) ••3433 Web: s' ov.a <br /> —u <br /> 2416 <br /> COMPLIANCERETURN TO i i I <br /> Any I3 violations noted in the"Notice to Comply"in thea ed Inspection Report must be+ WTfo <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address <br /> at the top of this form within 30 days of receipt of the Inspection Report MSG 25404.1.2(c)(1) <br /> Ail oorre 'o a jo other violations noted in the attached Inspection Report(IR)or Continuation Form, or disputes to any <br /> violations,are to be submitted using this certification and returned to EHD within unless otherwise specified in the <br /> 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 current hourly rate. <br /> For 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 /> Copies of sample results/manifests/training records/other appropriate paperwork,and/or photos verifying <br /> Corrections <br /> Inspection Date: January 25, 2016 Inspected By: STACY RIVERA <br /> ,,-�acilityAddress: 41.E MAIN ST, RIPON EPA ICS: <br /> (certify under penalty of law that <br /> 1. I have corrected the vicWtions.specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information to be true, accurate, and complete: <br /> Photos Paperwork______Statement <br /> 3. 1 am authorized to 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 <br /> and/or imprisonment for known violations. (HSG 25181) <br /> ti <br /> Name: Title: t "w <br /> Signature- Dake: <br />