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Y <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.or /q ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <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 wit1vin 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 Inspection Report(W)or Continuation Form, or <br /> disputes to any violations, are to be submitted using this certificabor and ret...Y-*d to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. HSC 25185(-', <br /> Note: All EHD staff time associated with failing to compty by the move noted dates will be <br /> billed at the current hourly rate. <br /> For this certification to be complete the op-1 -f4�- must include: <br /> • A statement documenting what corrective actions were take V. km, for each violation <br /> • Copies of sample results/manifests/training records/other ,a;r, •: - �e ;,A5 r- xork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: My 15, 2013 Insp+ . 3y --ett Backus <br /> Facility Address:2121 N Zuckerman Road EPA CA <br /> certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Pp„�_ + fro above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined the following documentation suam-treo ar% :roof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true, ac;-,Oate y od complete: <br /> Photos X Paperwork _Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violation^s. (HSC 25191) <br /> I f �✓LJ��� V7 <br /> Name:_ A C 73 Title: <br /> Signature: <br /> R'�� Date: <br /> EHD 22.02-005 Rev MOM <br />