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SAN aJOAQUIN COUNTY REcavEiL) <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 868 East Hazelton Avenue, Stockton, California 95205-6232 ISN 2 2 2015 <br /> Teleph ne: (209)468-3420 Fax:(209)468-3433 Web:www.sl4ov.org/eh <br /> ENVIRONMENTAt <br /> FA!Tia nr:Dj%oTAocAIT <br /> RET RN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations no ed in the "Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 days f receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health De artment (EHD) address at the top of this form within 30 days of receipt of the <br /> Inspection Report. HSC 5404.1.2(c)(1) <br /> All corrections to other vi lations noted in the attached Inspection Report (IR) or Continuation Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specifie in the Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff ti a associated with failing to comply by the above noted dates will be <br /> billed at the cur ent hourly rate. <br /> For tI11S C@rtIfICa ion t0 be completethe operator of the site must include: <br /> • A statement docume ting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample res Its/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certificatio <br /> Inspection Date:A v c13 1, 2o14 Inspected By: S aC Cf VQ.1-6 <br /> Facility Address: EPA ID# <br /> I certify under penalty flaw that: <br /> C.� /0 ooy033 3 <br /> 1. 1 have corrected th violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally xamined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATIO and I believe the information to be true, accurate, and complete: <br /> Photos_Paperwork _Statement <br /> 3. 1 am authorized to ubmit this certification on behalf of the Respondent. <br /> 4. 1 am aware that th re are significant penalties for submitting false information, including the <br /> possibility of a fineand/or imprisonment for known violations. (HSC 25191) <br /> Name: CAkt ,42 Title: a OjL <br /> Signature: Date: G 2— l <br /> EHD 22-02-005 Rev 04/19/12 <br />