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San Joaquin County <br /> Environmental Health Department R - <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 y <br /> " ,a>,: E <br /> Telephone: (209)468.3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> APR <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> ENVIRONMENTAL <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be Goi7 t l v°J tliirr M"d&bf <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 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 /> 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 <br /> corrections <br /> Operator's certification <br /> Inspection Date: January 07,2016 inspected By: Stacy Rivera <br /> Facility Address: 2700 W WASHINGTON ST CERS ID: 10182267 <br /> 1 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 imprisonment for known violations. (HSC 25191) <br /> Name:77%�AaY "3 Josda``P' Title: se„,�oo� r1ss� C'n.•�lla.wae SPce�s� <br /> Signature: Date. ljApr 00/9 __ <br />