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02/07!2014 22:47 F.tl 0003 <br /> S6;Yr <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1 m East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephdne. (299)468-3420 Fax: (209)468-3433 Web:www.sj ov.or leh if <br /> MAR 10 2014 <br /> RETYRN TO COMPLIANCE CERTIFICATI" <br /> EN At <br /> Any MI NOR.violations not Id in the 'Notice to Comply" in the attached Inspection Report� ��VjC r9 <br /> corrected within 30 days o receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Dep rtment (EHD) address at the top of this form within 30 days of receipt of the <br /> Inspection Report. HSC 2$404.1.2(c)(1) <br /> All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br /> disputes to any violations, gre to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. HSC 251 B5(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/traiining records/other appropriate paperwork, and/or photos <br /> verifying corrections j <br /> . Operator's certificatio <br /> Inspection Date: Inspected By: J� <br /> Facility Address: 153 E, 1 ) A e EPA ID#: <br /> I certify under penalty 9f law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally a amined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION nd I believe the information to be true, accurate, and complete: <br /> �_Photos Paperwork Statement <br /> 3. 1 am authorized to oubmit this certification on behalf of the Respondent. <br /> 4. 1 am aware that thee are significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: s Nr�y PmCFTitle: Cl(�}ti tLA <br /> Signature: e `lam `�`�' Date: <br /> EHQ 22-02-005 Rev 4/12 <br />