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Firefox about:blank <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue,Stockton,California 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www:s' ov.or /ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MI ICOR,violations noted in the"Notice to Comply"in the attached Inspection Report must be <br /> corrected within 30 dans 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 /> 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 /> displaces to any violations,are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the 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 <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: December 23, 2019 Inspected By:Lydia Baker <br /> Facility Address:3615 S HWY 99 W FRONT EPA ID#: CAL000349067 <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 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 <br /> possibility of a fine and/or Imprisonment for known violations. (NSC 25191) <br /> Name: -ems �� Title: <br /> Signature: Date; © 4c� <br /> EHD 22-02-005 Rev 04/19112 <br /> 1 of 1 10/7/2020, 12:00 PM <br />