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SAN JOAQUIN Environmental Health Department � <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> AnyIM NO violations noted in the"Notice to Comply' in the attached Inspection Report must be corrected within 30 alas of <br /> receipt of this Inspection. This certification form must be submitted to the Environmental Health Departmenf(EHL)address at ' <br /> the bottom of this fond within 30 days cf receipt of the Inspection Report HSC 25404.1.2(c)(1) j <br /> All correctiene to other vielabons noted m the,attached Ins paction Report(IR)of Continuation Form,of disputes to any <br /> violations,are to be submitted using this certification and returned to El D within 30 clays unless otherwise 9peculed in the <br /> Inspection Report, HSC 25185(x)(3) <br /> Note: All END 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 operator ofthe site must include: <br /> A statement documenting what corrective actions were taken or will be taken for each violation <br /> Copies of sample resultslmanlfestsoraining records/other appropriate paperwork,andior photos verifying corrections <br /> Operators certification <br /> Inspection Date: April 25, 2013 Inspected By: CESAR RUVA.LCA€3A <br /> Facility Address: 24717 E BRANDT RD, LDDI CERS ID: 10153309 <br /> I certify und,��eeJ;;r penalty of law that: <br /> 1. I�� Icorrecte l violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and <br /> I believe the information to be true, accurateand complete' <br /> Photos Paperwork `/ Statement <br /> 3. I am authorized to submit this cedlfication an behalf of the Respondent <br /> 4. 1 am aware that there are significant penalties for submitting false information,including the possibility of a fine andior <br /> imprisonment for known violations (HSC25191) <br /> Name: �'R'Ut'- nka2vizjo Title: �Nlk'io��'ta,✓-��7� n/-,�q5 <br /> Signature: Date'. <br /> 1866 E. Hazelton Avenue I Stockton, California 95206 1 T209468-34201 F 209 464-0138 j www.sjcehd.com <br />