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10/15/2015 4:46 PM FA% fdj 0002/0006 <br /> • San Joaquin Co my • <br /> Environmental Health D pa ment RE HVEL <br /> 1368 East Hazelton Avenue, Stockton, Cali ornia 95205-6232 <br /> Telephone:(209)468-3420 Fair:(209)468-21433 eb:www sLoov ora/ehd p 715 2015 <br /> RETURN TO COM LIANC C RTIFICATIOlf-MI ONMENTAL <br /> HF:Al anaMPTAACkrr <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be of <br /> receipt of this inspection. This certification form must submitted to the nvironmental Health Departmen (EHD)address: <br /> the top of this form within 30 days of receipt of the Insp ction Report. HSC 25404,1.2(c)(1) <br /> All corrections to other violations noted in the attached Inspection Report(I )or Continuation Form, or disputes to any <br /> violations, are to be submitted using this certification and returned to F,HD Iviftn 30 days unless otherwise specified in the <br /> Inspection Report, MSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to om ly by the above noted d ites 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 wi I be taken for each violation <br /> Copies of sample results/manifests/training records/other app <br /> rinspected <br /> pn to paperwork, and/or photos verifying corrections <br /> Inspection Date: September 15, 2015 By: JAMIE DE LA ROSA <br /> Facilq Address: 2354 N WILCOX RD. STOCKTON EPA ID: <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report frc m the above-mentioned inspecti Din date, <br /> 2. 1 have personally examEned the following documentation submittec as proof of compliance FOR U CH VIOU TION <br /> I believe the information to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent <br /> 4. 1 am aware that there a'e significant penalties for submitting I Mse nformabon, including the possibi ity of a fin and/ <br /> imprisonment for known violations_ (HSC 25191) <br /> Name: del11& gi[ .MbY- Title: <br /> Signature: kas+-0111Ak' GlA7__) i Date / <br />