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S p 2 3 Z013 SAN JOAQUIN COUNTY (� <br /> EN1/IRONMENTAL HEALTH DEPARTMENT �'��-a.c�-�.SJL ' <br /> tM East Hazelton Avenue, Stockton, California 95205-6232 <br /> ENVIR ,M�Mne:(209)468-3420 Fax,(209)468-3433 Web:www.s' ov_or /ehd <br /> P . <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 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 cnrrectidns to other violations noted in the attached Inspection Report(IR) ur Continuatlon 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. HSG 25185(c)(3) <br /> Note: All �HD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For thi 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/other appropriate paperwoi k, and/or photos <br /> verifying corrections <br /> • Operatr's certification <br /> Inspection Date: August 29, 2013 Inspected B :Garrett Backus <br /> p y <br /> Facility Address-.7700 Moreland Street EPA ID#: <br /> I certify tinder penalty or law that: <br /> 1_ I ha�e corrected the violations sperifiad in the Inspection Report from the above-mentioned <br /> inspection date. <br /> ✓2. l have personally examined mu rvllowing documentation submitted as proof of compliance FOR ,^ <br /> EACH VIOLATION and I believe the inf ation to be tr e, accurate, and c mp ete: <br /> Phofos P_apeIr o �-Stateme I IL..Q--vK �! <br /> 3. 1 am authorized o submit this certification on behalf of tele Respondent. ctCT—"_ <br /> 4. 1 am aware that there are significant penalties far-;obmitting false information, including the <br /> poss bility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: Title: <br /> Signa Date: <br /> EHO 22-02-005 Rev 04/19/12 <br />