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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Telephone:18East Hazelton Avenue, Stockton, f <br /> e:(209)468-3420 Fax: (209) 468-3433 Web.ornia w � <br /> www-sigov.org/eh ora/ehtl °16 .�3 � <br /> JUL Qa `L 2013 <br /> RETURN TO COMPLIANCE CERTIFICATIONN"`F � l�; <br /> Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the <br /> Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other violations noted in the 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 be <br /> billed at the current hourly rate. <br /> For this certification t0 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/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification , 1 <br /> Inspection Date: (/ L� I�-�( 3 Inspected By: Jf" WOt^r1 <br /> Facility Address: ) 400 1�YIt7o 1��1LC EPA ID#: CAD 1 1 570,1 `425- <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and lieve the infor Ion to be true, a ate, and complete: <br /> PhotosPaperwork 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 <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: �'yr— Title:�ArIvWTJ�nI AAY1 <br /> Signature: Date: <br /> EHD 22-02-005 Rev 4/12 <br />