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IOU San Joaquin County <br /> 3"ua r 7 0I_5 • Environmental Health Department • RECEIVED <br /> .J 1868 East Hazelton Avenue, Stockton, California 96205-62.32 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web,wwwsiogy orm/ehd JAN 06 2016 <br /> RETURN TO COMPLIANCE CERTIFICATIONENVIRONMENTr . <br /> Hr&ITw nr mnDTAAcMT <br /> Any_LINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be corre within0days of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address <br /> the top of this form within 30 days of receipt of the Inspection Report. HSC 25404,1.2(c)(1) <br /> All corrections to other X12Mons noted in the attached Inspection Report(IR)or Continuation Form, or disputes to any <br /> violations, are to be submitted using this certification and returned to EHD within 3Q_ acmes_unless otherwise specified in the <br /> 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 to 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 verifying corrections <br /> Inspection Date: December 08, 2015 Inspected By: STACY RIVERA <br /> Facility Address: 810 S MONROE_ST. STOCKTON EPA ID; <br /> 1 certify under penalty of law that <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> I believe the information to he 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 are significant penalties for submitting false information, including the possibility of a fine and/ <br /> imprisonmmenttforknownviolatiioons-s- ((HHS�C,25191) <br /> Name: I`- tJ G �nJ v7 `�.v"( T•ttle:l , <br /> Signature: d �_ Date: <br /> � oL <br /> �jo7a <br /> �ppl <br /> � � s <br />