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09/23/2014 16:27 209466 SJC EHA UNIT 3 PAGE 06106 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1866 East Hazelton Avenue, Stockton, California 95205-6232 0 C T 012014 <br />Telephone; (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov,oratehd <br />ENVIRONMENTAL HEALTH <br />5EI5A_RTMMT <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 ce' Mciation form must be submitted to the <br />Environmental Health Department (EHO) address at the top of this form within 30 days of receipt of the <br />Inspection Report. HSC 28404.1,2(c)(1) <br />All corrections to other violations noted in the attached inspection Report (IR) or Continuation Form, or <br />disputes to any violations, are to be submitted.using this certiflCaiion and retumed to EHO within 30 days <br />unles%otherwise specified, in the:lnspeetion Report_ HSC25185(r,)(3) <br />Note: All EHD-staff time associated with failing to comply by theabovenoted 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/manifesis/train'ing records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Data: June. 12,..20,14 Inspected By: Elena Manzo <br />Facility Address.. 1399 E'Yosernite Avenue EPA ID# <br />I certify under penalty of law that: <br />I. I have corrected the:vioiations-specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos L/'�perwork Statement <br />3. 1 am authorized to submit this certification on behalf of the Respondent. <br />4. 1 am aware thatthere are significant penalties for submitting false information, including the- <br />possibility <br />hepossibility of.a.fine and/or imprisonment for known violations. (HSC 25191) <br />Signature: Date: <br />EHa22-42-000 Rev04/19nz <br />