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Feb,27. 2015 1:49PM FACILITIES MGMT <br />0 No. 9162 P. 3 <br />Son Joaquin County RECEIVED` <br />Environmental Health Department <br />1868 East HaZelto'n Avenue, Stockton, Califiorrile 95205-6232 FEB 2 7 2015 <br />relaphone: (209) 488-3420 Fhx- (209) 488-3433 Web., MMAWM04Wd <br />ENVIRONMENTAL <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any M= violations noted In the 'Notled to CompV in the attached Inspection Report must be rreated wid,l dans of <br />receipt of this Inspection. This certification form must be submitted to the ft-ironmental Health Department (EHD) address <br />at the top cf this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br />All .corre ns to offer 1d=noted In the attached Inspection Report (IR) or Continuation Form, or disputes to any <br />vlolations, are to be submitted using this certification and returned to EHD WAWajQ-dW unless otherwise specified In the <br />Inspection Report HSC 25186(c)(3) <br />740te: All EHD staff fime assoelated with failing to comply by the above noted dates will bi,� <br />billed at the eurrent hourly rate. <br />For this certification to be complete, the operator of the alto must include; <br />A statement documenting what corrective actlons were taken or wlh be taken for each violation <br />Copies of sample results/mariffes"aInIng re001`410thOr appropriate papeirwork, and/or photos verifying <br />Corrections <br />inspection Date: November 21, 2014 Inspected M VELOSO <br />Facility Address: 1420 N TRAcy 13LVD, TRACY EPA' <br />I Certify under penalty of law that: <br />I. I have corrected the violations specified In the Inspection Report from.the above-mantioned Inspection date. <br />C I have personally examined the MlowIng documentation submitted as proof of compliance FOR EACH IVIOLATION <br />and I believe the Information to be true, amrate, and completeg. - <br />—photo$ -��A—Papefwcrk —Statement <br />3. 1 am authorized to submit this certification on behalf of the Respondent <br />4, 1 am aware that there are significant penelllqs for submitting false Information, Including the possibility of a fine <br />and/or Imprisonment for known violations, (HSC 26191) <br />Name:--dZZ&,9E A.ate 41 Ze— tie: Z�l <br />SignatuRn <br />