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San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California 6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web::wwwswww.sijgov.org/ehd <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 /> 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 violations noted in the attached Inspection Report(IR)or Continuation Form, I s t a_ <br /> violations,are to be submitted using this certification and returned to EHD within 30 days unless othe <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All EFED staff time associated with failing to comply by the above nates wit bd <br /> billed at the current hourly rate. Z 1 99 MENTA 1 <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 betaken for each violation <br /> Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br /> Inspection Date: February 23 2016 Inspected By: GARRFTT BACKUS <br /> Facility Address: 18662 N HWY 88 , LOCKFFORD EPA ID: <br /> I 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 pr of compliance FOR EACH VIOLATION <br /> and I believe the information to be true,accurate, a 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 pe ties for submitting false information, including the possibility of a fine <br /> and/or im nment for kn violation . (HS 5 91) <br /> IName: <br /> (Signature: Date: 31 3d <br /> -73 <br /> ! <br /> 600/ L00'd 9Le L# H99BB££50Z £Z:ZL 9TOZ/LO!£0 <br />