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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> _Te+18]7hme€(209r468=3420-FaA. /efi9 -- <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 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. HSC 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 results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections # rpg Gc.R (a�ea�eo�. 1 I <br /> • Operator's certification <br /> Inspection Date: 54 k4 15 2� aQ 141 Inspected By: L C <br /> Facility Address: 1614A 'sItarlon Q�_ EPA ID#: (4ARp©w0Qr7r19o9 <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_Statement <br /> 3. I am authorized to submit 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 e nd/or imprisonment for known violations. (HSC 25191) <br /> Name: t Title: Gr I <br /> Signature: Date: r/ I ) <br /> 5t�ttC tw (',t'c{fhs. wort c Mf t i c L intZD f t�� ai <br /> c ortwi�tTS . S012'1 af(k 5 uwcf� 0, L ul1) 4nL <br /> EHD22-02-005Rev OB/11 f LAL Inlro 5c-raf (h&trLf <br />