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2015-02-18 14:49 Safeway 2707 2094728604 >> 209L`9433 P 1/6 <br />San Joaquin County <br />Environmental Health Departmentr ���jC1 <br />1668 East Hazelton Avenue, Stockton, California 95205-6232 14/. <br />Telephone: (209) 468-3420 FaX: (209) 46&3433 Web: www.sigov.orolehd <br />RETURN TO COMPLIANCE CERTIFICATION FEB 18 2015 <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of TAI-- <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address <br />at the top of this form within 30 days of receipt of the Inspection Report, HSC 25404.1.2(c)(1) <br />All noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br />violations, are to be submitted using this certification and returned to END within 30 days unless otherwise specified in the <br />Inspection Report. MSC 25185(c)(3) <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 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/manifests/training records/ather appropriate paperwork, and/or photos verifying <br />corrections <br />Inspection Date: January 22, 2015 Inspected By: FATINAH ZAREEF <br />Facility Address: 6425 N PACIFIC AVE, Stockton EPA ID: <br />I certify under penalty of law that - <br />1 . <br />hat -1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2. 1 have personally examined the fallowing documentation submitted as proof of compliance FOR EACH VIOLATION <br />and I believe the information to be true, accurate, and complete: <br />Photos 74' 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 penalties for submitting false information, including the possibility of a fine <br />and/or imprisonment for known violations. (HSC 25191) ('` I <br />Name:'-: v : 1 G-L� Title: (L t/A <br />Signature: Date: <br />