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San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, California 95206-6232 <br />UF <br />17F piiWZ�ZIPI% 46&3420 Fax.,:1209f, 468-3433 Web: EN <br />RETURN TO COMPUANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrects d w!1bkLN-days Of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EI -10) address <br />at the top of this form within 30 days of receipt of the Inspection Report HSC 25464.1.2(c)(1) <br />All corwffnna to g1her v'ii lige noted in the attached Inspection Report (tR) 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 />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/manifestOraining records/other appropriate paperwork, and/or photos verifying <br />corrections <br />Operator's certification <br />a =- T n -M -6 a C--2 <br />September 23, 2013 <br />Facility Address: 2072 W YOSEMITE AVE <br />I certify under penalty of low that <br />Inspected By: Elena Manzo <br />CERS ID: 10181669 <br />1. I 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 ___---YaPerwOrk Statement <br />3, lam 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 2 fine <br />andlor imprisonment for known violations. (HSC 25191) <br />{�'�Ftj '/� 7GSfi A <br />__,_2 -,d-- / ? <br />g,d OOL9VZ960Z cloqSNoinb dZo: Lo j I. 90 Inr <br />