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A% <br /> San Joaquin County RECEIVED <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue,Stockton,Califbmis 96205-62,S2 MAS 2 12017 <br /> ratephone:(209)468-3420 Fax:(209)468-343$ Web:Wmu,,9-fgmLgr_q/_ehd <br /> RETURN TO COMPLIANCE CERTIFICAfkWON MENTAL HEALTH <br /> DEPARTMENT <br /> Any-WHO-2 vlolations noted in the'Notice to Comply"in the attached Inspection Report must be g=%=ALthlqZ days of <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. HSC 25404.1.2(c)(1) <br /> All gmetions to otherviol ations 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&ftNn-aQA&_s unless otherwise specified in the <br /> Inspection Report. HSC 2518$(c)(3) <br /> Note., All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the cument 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 resultsimanifests/training reoords/other appropriate paperwork,and/or photos verifying <br /> corrections <br /> Operators certification <br /> Inspection Date., June 13,2016 Inspected By: Fatinah Zareef <br /> Facility Address; 3304 W HAMMER LN CERS 1D- 10184253 <br /> 1 certify under penalty of law that: <br /> 1, 1 have corrected the violations specified in the Inspilidon Report from the above-mentioned inspection date, <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLA-nON <br /> and I believe the information to be true,accurate,and complete, <br /> Photos ligaperwork_Statement <br /> f <br /> 3. 1 am authorized to submit this cartift'ation 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. (HSC 25191) <br /> Name: CzeA .2d=:2 <br /> Signature: Date: <br />