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' | <br /> | RECEIVED <br /> SAN Jom3u)wCOUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT APD 15 2014 <br /> 18§OEast Hazelton Avenue, Stockton, ( |iho i 95205-6232 <br /> Te/ephone: (2O9)468'342OFax:(2OS)46A-34 33 Web: www;sic <br /> L HEALTH <br /> DEPARTMENT <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations rioted in the "Notice to Comply" in the ottached Inspection Report must be <br /> corrected within 30 days ofreceipt ofthis inspection. This cetifih form must bosubmitted tothe <br /> Environmental Health Department (EHD) address at the top cf this form within 30 days of receipt of the <br /> Inspection Report. HSC25404�.2(o)(1) � <br /> All corrections to other violations rioted inthe attached |napection Repnr-t (UR) nrContinuation Form, or <br /> disputes to any violations, are to be submitted using this cehi,ioadon and returned to EHO within 30 days <br /> unless otherwise specified in the Inspection Report. HSC 25' 85(o)(3) ! <br /> . � <br /> Note: All EH0 staff time associated with failing to ucmnply by the b oted dates will be <br /> billed etthe current hourly rate. <br /> For this certification to ue comp|ef <br /> ethe <br /> operator— of <br /> ^ Astak,men\ documenting what corrective actions were i1kon or will be taken for each violation <br /> ° Copies of sample results/manifests/training records/othe-appropriate paper-work, and/or photos <br /> verifying corrections <br /> ~ Operator's certification <br /> -- -----------------------'--------------- ---------- --- --| <br /> AP /\Fi3 Ci ' <br /> InspectedInspection Date: By- ``�r ^ | <br /> Facility Address: EPA ID#: L � <br /> I certify under peria of law that: <br /> 1. 1 have corrected the violations specified in the <br /> � <br /> innReport from the above-mentioned <br /> inspection date, <br /> � <br /> 2. 1 have personally examined the following documentat <br /> on submitted ayproof oTcompliance FOR | <br /> EACH VIOLATION and I believe the information to bE truu, accurate, and complete: / <br /> 3. 1 am authorized to submit this certification on behalf cl 7 the Respondent. <br /> 4. 1 am aware that there are significant penalties for sub nitting false information, including the <br /> possib f a fine and/or irn—p)isonr-nent for known viclations. (HSC 25191) <br /> I Signature: late: <br /> svoz2-n2-o05n,wmynz ' <br /> ^ � <br /> | / <br />