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San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue. Stockton, California 9520&6232 <br /> Telephorm. (203)468-3420 Fax:(209)468-3433 Web:www sjpov.orglend <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations. noted in the"Notioc to Comply° in the attached Inspection RepW must be cocrectad within 30 days 0: <br /> recopt of this inspec:txxn. This owtification form must be submitted to the EnvlrGrimental 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 cxirrertions- to ottser vim or:s noted in the anached inspection Report(iR-1 or Continuation Form, or disputes to any <br /> violations, are to be submitted using thri certificnatk-m and returned to END within 30 days unies otherwise specified in tris <br /> 1nspectron Report HSC 25185(c)(3'1 <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 to be complete, the operatcx of the site must include' <br /> A statement docurnunting what corrective aeons were taken or will be taken for each violation <br /> Copies of sample resultslmarifests,rtfaining rec:ordslother appropriate paperwork, anrVor photos verifying corrections <br /> Inspection Date: A n! 11 Inspected By: V"UK, NA1QCARTNCR <br /> Facility Address: 257 7 5 'S-PA F T EPSON PASS RD, TRACY EPA U. <br /> I certify under penatty of law Mat. <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-meritKmed cnspFction date F <br /> 1 <br /> 2 1 hayG personalty oxarnrnod the folkming documentation submittal as proof of ro mpliance FOR EACH VIOLA I ION <br /> I believe the informatiDn to be true, aeourate, and c u,,nplete af' <br /> Photos �i_Paperwork V Statement <br /> 3 1 am authorized to submit lhiy ceitifrc:abann on behalf of the Respon0en1_ <br /> 4 I am ama"o Viat utcre arc significant penalties for submitting fal;sc mlormation, including the possioility of a hrX,arul <br /> imprrsonrnent for kncnvn violations (HSC 25191) _ <br /> N:�nic: - �� '�- Title _ } - <br /> �' <br /> Signature: <br /> MAY 05 j <br />