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FROM FAX NO. tg. 2e 2014 03:41PM P2 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 AUG 2 8 2014 <br /> Telephone:(209)468-3420 Fax.(209)488-3433 Web:www.siaov.org1ehd <br /> HEALTH <br /> RETURN TO COMPLIANCE CERTIFICATION EpARTMENT <br /> Any MINOR violationsoted in the"Notice to Comply'in the attached Inspection Report must be <br /> corrected within 30 da of receipt of this inspection- This certification form must be submitted to the <br /> Environmental Health bepartment(EHD) address at the top of this form within 30 days of receipt of the <br /> Inspection Report. HSG 25404.1.2(c)(1) <br /> All corrections to other iolations noted in the attached Inspection Report(IR)or Continuation Form, or <br /> disputes to any violatiol is, are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specill ed in the Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff I ime associated with failing to comply by the above noted dates will be <br /> billed at the c irrent hourly rate. <br /> For this certification t0 be Complete the operator of the site must include: <br /> . A stateme t documenting what corrective actions were taken or will betaken for each violation <br /> • Copies of 3ample sults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying rrectio s <br /> • Operator' certification <br /> Inspection Date: f f' Inspected 6y: r}'1 /G�io�� �?. )4�Pn/Y <br /> Facility Address: )S�W !11_h St -T-tq 61 EPA ID#: O, C)00,9q�r 17 b <br /> I certify under penalty of law that; <br /> 1. 1 haverrecte the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have 1�ersonal[V examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATI N and I believe the information to be true, accurate, and complete: <br /> Photos )41 Paperwork V- Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. I am aware that there are significant penalties for submitting false information, including the <br /> possibility of a fi a and/or imprisonment for known violations. (HSC 25191) <br /> Name: P� �c�ca� Title: �i's ►�� f9la �x <br /> Signature. Date: c'f! <br /> EHO 22-02-005 Rw 04/19/12 <br />