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06/11/2013 10:50 2093344684 <br />SAN JOAgUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, California 95205.6232 <br />Telephone: (209) 468.3420 Far (209) 468-3433 Web: www_siaov.ora/ehd <br />RETURN TO COMPLIANCE CERTIFICATION <br />05146 P.001 /002 <br />RC JLW L: <br />JUN 11 2013 <br />1 ' IENTAL <br />Ucn111 ------- <br />Any--_.__ <br />Any MINOR violations noted in the "Notice to Compty" 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 (£HD) 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 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 specified in the Inspection Report. NSC 25185(c)(3) <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate. <br />For this certification t0 be Complete 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 resultstmanifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: 2Q1 3 Inspected By: <br />Facility Address: 101 <br />um qCq2WEPA ID#: <br />LYIK <br />0�q_ &-a <br />I certify under penalty of law that: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos Paperwork C tatement <br />3. 1 am authorized to submit this certification on behalf of the Respondent. <br />4. 1 am aw hat there are signifi penalties for submitting false information, induding the <br />possi(�lity of fine and/or impri onm #for known viola#ions. (HSC 25191) <br />Na me. <br />yw rC Title: , <br />Date: <br />EHD 22-02-00.5 Rw04119112 <br />