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RECEIVED <br /> SANJOAQUIN COUNTY AUG 2016 <br /> ENVIRONMENTAL RTMENT <br /> HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton,California 95205-6232 ENTAL H <br /> Telephone.(209)468-3420 l:ax:(209)468-3433 Web:www siao§AW!$S"PERM1T/SE EALTH <br /> cp <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) IR or Continuation Eorm, or <br /> All corrections to other violations noted in the attached Inspection Report( } <br /> disputes to any violations, are to be submitted using this certification and returned to EHb within 3o days <br /> unless otherwise specified in the Inspection Report. HSG 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 /> r . A statement documenting what corrective actions were taken or will be faken for each violation <br /> results/manifests/trainin <br /> . Copies of sample g records/other appropriate paperwork, and/or photos <br /> verifying corrections hv-efx IY1SPe, Cir'o -rim Y1 i <br /> . Operator's certification �rjDd4� d} <br /> C _ ? inspected By:Stacy Rivera <br /> inspection Date: — <br /> Facility Address: `�-c� `6 EPA ID#:/ q )Q02f�-60 y <br /> C, S�Ic Wu� f�i <br /> I certify under penalty of law that: <br /> 1 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> C <br /> inspection date. <br /> 2 1 have EACH VIOLATIIONexamined <br /> and I believe the information tobehe following documentation <br /> true,accurate,submitted <br /> acompliance FOR <br /> 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 <br /> possibility of a fine and/or imprisonment for known violations. (MSC 25191) <br /> `- Title: d V1,44e12 <br /> NameX n <br /> Signature) �e 1n��L Date: �' a <br /> 1' 6 <br /> END 22-02-005 Rev 0019/12 <br /> :2 <br /> E0:TL 9S0Z/LZ/90 Q3AI303b <br />