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SAN JOAQUIN COUNTY <br /> EN ONMENTAL HEALTH DEPARTMENT <br /> 1868 East H ton Avenue, Stockton,California 95205-6232 <br /> Telephone:(209)46 -3420 Far:(209)468-3433 Web:www.sioov.ora/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any IM N R violations noted in the "N ice to Comply" in the attached Inspection Report must be <br /> core cted within 30 days of receipt of is inspection. This certification form must be submitted to the <br /> Envonmental Health Department(E ) address at the top of this farm within 30 days of receipt of the <br /> Inspection Report, HSC 25404.1.2(c) ) <br /> All corrections to other violations note in the attached Inspection Report(IR) or Continuation Form, or <br /> disputes to any violations, are to be s miffed using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Insp ction Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associ d with failing to comply by the above noted dates will be <br /> billed at the current hour) rate. <br /> For this certification to a complete the operator of the site must include: <br /> • A statement documenting what rrective actions were taken or will be taken for each violation <br /> • Copies of sample results/manife sAraining records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date:April 3, 2013 Inspected By:Aris Cacapit <br /> Facility Address:2500 W. Lodi ve. EPA ID#: CAR000142463 <br /> I certify under penalty of law that: <br /> 1. I have corrected the violation specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined t following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I bell ive the information to be true, accurate, and complete: <br /> otosPaperwork 7tatement <br /> 3. 1 am authorized to submit thi certification on behalf of the Respondent. <br /> 4. 1 am aware that there are sig ficant penalties for submitting false information, including the <br /> possibility of a fine and/or im ison r known violations. (HSC 25191 <br /> Name: Title: <br /> Signature: Date: <br /> eMDzzaz-oosae.wn�iz APR 16 2013 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />