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REGEIVEC <br /> San Joaquin County <br /> Environmental Health Department SEP 10 2015 <br /> 1868 East Hazelton Avenue, Stockton, CalKomia 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.gigg,,t.org/e cN v IRON v ENTAL <br /> ir� rU r?C')�n.rgACI�T <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any M1 violations noted in the"Notice to Comply" in the attached Inspection Report must be corr=d within 30 days 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 Qther violation 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 30sfM unless otherwise specified in the <br /> Inspection Report, HSC 25185(0)(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 recordslother appropriate paperwork, and/or photos verifying corrections <br /> Inspection Data: August 18, 201 Inspected By; FATINAH ZAREEF <br /> Facility Address: 6131 PACIFIC AVE STOCKTON EPA 113, <br /> I certify under penalty of law#Y,& <br /> - <br /> 1. 1 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 be 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 /> imprisonment for known violations. (HSC 25191) <br /> Name:_ [ �r ✓i`� f2 AtZ Title: <br /> 12Signature: c Date: — _ `� <br />