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SAN JOAQUIN COUNTY OCT 15 2014 <br /> ENVIRONMENTAL HEALTH DEPARTMENT �11V1gONAgF �• <br /> 1868 East Hazelton Avenue,Stockton,California 95205-6232 PERtU1fT MA(y t. <br /> Telephone:(209)468-3420 Fax:(2159)468-3433 Web,M8M sl ov.oh._ ro/ehd �S��ICES�l r4 <br /> F' <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 da vs of receipt of this inspection. This certification form must be submitted to the { <br /> Env(rbAriental Health Department(EHD)address at the top of this form within 30 days of receipt of the f <br /> Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other violations noted In tile attached Inspection Report(IR)or Continuation-Form,or <br /> disputes to any violations, are,to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will he <br /> billed at the current hourly rate. <br /> For certification to be corn letetneoperatorofthesitemustInclude: <br /> e A statement documenting what corrective actions were taken or will be taken for each violation <br /> o Copies of sample results/manifeststtmining records/other appropriate paperwork, and/or photos <br /> I. <br /> verifying corrections <br /> • Ciperator's certification <br /> i <br /> Inspection Date:September 18, 2014 Inspected t3wFatinah Zareef <br /> Facility Address:4040 West Ln, Stockton .CA EPA tD#: C-AD981390073 <br /> F <br /> I certify under penalty of law that: <br /> i <br /> 1 1 have corrected the violations specified in the Inspection Report from the above-fnehtioned <br /> r <br /> Inspection date. s <br /> 2. 1 have personally examined the following dobumentalion submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true,accurate,and complete: s <br /> Photos--X—paperwork_'�C_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 far submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Nance: , e S ee Title:JE /IARnA//'tr<NT/dL r161- <br /> SAF .4 t,tsT 7 <br /> Signature: <br /> 44 <br /> I Date: l o I J' i <br /> EHD 22-02-005 Rev 04119A2 <br />