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i <br /> San Joaquin County V 'v <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue , Stockton , California 95205-6232 c g 6i, u Z{ 10 <br /> Telephone: (209 ) 468-3420 Fax: (209) 468-3433 Web www. sigov. /ehd <br /> FWRONMENT& HEAt_Tl <br /> i <br /> RETURN T COMPLIANCE C TIFICATI PERNIiT�ERVICES <br /> Any MINOR violations noted in the " Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection . This certification form must be submitted to the Environmental Health Department ( EHD) address ; <br /> the top of this form within 30 days of receipt of the Inspection Report, HSC 25404. 1 :2( c) (I ) <br /> All corrections to 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 30 days unless otherwise specified in the <br /> Inspection Report. HSC 25185(c) (3) <br /> i <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 corrections <br /> Inspection Date : May 24 , 2516 Inspected By : ELENA MANZ4 <br /> Facility Address : 23555 KASSDN RD TRACY EPA ID: ¢ � � 47 7 �� <br /> Ism <br /> certify under penalty of law that: <br /> 1 . 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date . <br /> 2 . 1 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 X 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 imprjs.onment for known violations . ( HSC 25191 ) <br /> Name: /;7 1 v/ . .,� Title: <br /> Signature: '�'� f j ' Date: <br /> f <br /> i <br /> i <br />