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Jan vu i,+v.s,00p vaa,a'oav -,N UN 0'A"l.1'v00 do I IV 001i p.a <br /> Oc'djm 0 9 2014 SARI JC3AQUIN CoUmTy <br /> ENVIRONME14TAL HEALTH DEPARTMENT <br /> 1669 East Haze'ton Avenue,Stockton,California 95205-6232 <br /> Tetephonw(209)468-3420 Fax.(209)468-3433 Web:Www.siaose oreslehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any IVIINQR violations noted in the"Notice to Comply°in the attached I nspection Report must be <br /> corrected within 30 dam of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department(EH D)address at the top of this form within 30 days of receipt of the <br /> 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 <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 30 dais <br /> unless otherwise specified in the Inspection Report. HSG 2515(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 completethe 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 resultstmanifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> Orator's certification <br /> Inspection fate: January 9, 2014 Inspected By:Garrett Backus <br /> Facility Address:4344 E Waterloo Road EPA ID#: CAR000124008 <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined 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 v✓Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> . 1 am aware 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: t✓I <br /> Signature: Date: - IG. ®1 <br /> EHO 22-02-XS Rev 04;19112 <br />