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San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, California 95245-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web. www.sjgov.orglgh_d <br />RETURN TO COMPLIANCE CERTIFICATION <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 />at the top of this form within 30 days of receipt of the Inspection Report HSC 25404.1.2(c)(1) <br />All coa Erc +ciions to ether 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 />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/manifeststtraining nMcords/other appropriate paperwork, and/or photos verifying <br />corrections <br />Operator's certification <br />Inspection Date: September 23, 2013 <br />Inspected By: Elena Manzo <br />Facility Address: 2072 W YOSEMITE AVE CBRS ID: <br />I certify under penalty of law that: <br />10181669 <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 Statement <br />3. 1 am authorized to submit this certification on behalf of the Respondent <br />4. 1 am aware that tyre are significant penalties for submitting false information, including the possibility of a fine <br />and/or MIZn:sonment for known violations. (HSC 25191) <br />Sig <br />10 V, W <br />L <br />g•d <br />14,1 <br />Ll a6 <br />OOL9tVZ960Z <br />Date: :2 <br />r 5p <br />.ice nma <br />i <br />.,, p 7 201; <br />doyg Nolnb d90:Z 1, L 1, LO Inf <br />