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FROM FAX N0. y. 04 2016 12:14PM P5 <br /> San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, Califomia95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web.www.sigov.org/ehd AUG ® 4 2015 <br /> RE*URN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in Ithe"Notice to Comply"in the attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection. Thisrtification form must be submitted to the Environmental Health Department(EHD)address <br /> the top of this form within 30 daFs 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 sing this certification and returned to EHDwithin 30 days unless otherwise specified in the <br /> Inspection Report. HSC 25185 c)(3) <br /> Note: All EHD staffti a associated with failing to comply by the above noted dates will be <br /> billed at the currelit 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 recordsiother appropriate paperwork, and/or photos verifying correction: <br /> Inspection Date: Jul 1 , 2016 lnspected By: FATINAH ZAREEF <br /> Facility Address: 515 ELEVENTH ST. TRACY EPA ID: <br /> I certify under penalty of law th <br /> 1. I have corrected the vio ations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personally exa ned the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the inform tion to be true, accurate, and complete: <br /> Photos _Paperwork _Statement <br /> 3. 1 am authorized to sub it this certification on behalf of the Respondent. <br /> 4, lam aware that there a significant penalties for submitting false information, including the possibility of a fine <br /> and/or imprisonment for known violations. (HSC 25191) <br /> Name: '�'4 0 Title: M efo cr e l- <br /> Signature: Date: ~7 / V/ <br />