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0 0 <br />San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siaov.orglehd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br />rece pt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address <br />at 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 violations 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 30 days unless otherwise specified in the <br />Inspection Report. HSC 25185(c)(3) <br />All EMD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate. <br />Fo{ this certification to be complete, the operator of the site must include: <br />i A statement documenting what corrective actions were taken or will betaken for each violation <br />1 Copies of sample results/manifests/training recordslother appropriate paperwork, and/or photos verifying <br />corrections <br />ion Date: January 07, 2015 Inspected By: MICHELLE HENRY <br />Address: 192 Lathrop Rd, Lathrop EPA IML , AL 06025-991-2— <br />under <br />6025 -991 -- <br />under penalty of law that: <br />I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />I have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br />and I believe the information to be true, accurate, and complete: <br />PhotosPaperwork Statement <br />I am authorized to submit this certification on behalf of the Respondent. <br />I am aware that there are significant penalties for submitting false information, including the possibility of a fine <br />and/or imprisonment for known violations. (HSC 25191) <br />l_Z7 <br />6 <br />I,,'A- It5 <br />