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Dollar Tree Regional 2099825678 p.2 <br />SAN JOAQUIN COUNTY <br />Avenue, <br />1868 East Hazelton ECEIVED <br />• • t• 468m3420 1' 46:"3433 Webe www.siaov,orq1ehd JUL 2 4 2014 <br />enVIRONMENTAL HEALTH <br />ETURN TO COMPLIANCE CERTIFICATIONbEPARTMENT <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br />Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the <br />Inspection Report. HSC 25404.1.2(c)(1) <br />All corrections to other violations noted in the attached [nspection Report (1R) ar 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 specified in the Inspection Report. HSC 25185(c)(3) <br />Note: /�11 EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate. <br />FOi" t�iS CG'I�I�ICc��tOCI fi0 WJE C4i7ip�G�C? 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 <br />verifying corrections <br />• Operator's certification <br />Inspection Date; 2g ,��_ Inspected By: Stacy Rivera <br />I certify under penalty of law that: <br />1. I have corrected the violations specified in the Inspection Report from the above_mentioned <br />inspection date. <br />2. l have personally examined the following documentation submitted as proof of compliance FOR <br />F�ACH VIOLATIQN and I believe the information to be true, accurate, and cornp[ete: <br />Photos Paperwork t!J Statement <br />3. I 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 fine andlor imprisonment for known violations. (HSC 25191) <br />liiF1it <br />nature: <br />Title: 6A r�Ci f} 41UL,{,�/; ��`�� <br />540f Tfi v- � <br />Date: Z <br />EtiD 22-02-005 Rev 04/19/12 <br />54 <br />