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SAN JOAQUIN OOUNTY <br /> ENVIRONMENTAL HEAL H DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, Califomia 95205-6232 <br /> Telephone:(209)468-3420 Fax.(209) 8-3433 Web:www.sjgov.org/ehd <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 corrections to other violations noted in the attached Ir spection Report (IR)or Continuation Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to END 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. Fn <br /> For this certification to be comP let theREW, -` he site must include: <br /> • A statement documenting what corrective actions were taken or willbe MM each violation <br /> • Copies of sample results/manifests/training records ppropri <br /> other a � ork, and/or photos <br /> verifying corrections <br /> . Operator's certification ENVIRONMENINL.or �;�;,�TH <br /> RTMENT <br /> Inspection Date: May 15, 2014 Inspected By:Garrett Backus <br /> Facility Address:419 S Main St, Manteca EPA ID#: CAL000364723 <br /> certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the In pection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined the following docum ntation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true,_accurate, and complete: <br /> Photos Pap rwork 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 fol submitting false information, including the <br /> possibility of a fine and/or imprisonment for kno violations. (HSC 25191) <br /> Name: INA^ldA Title: <br /> Signature: Date: _ <br /> EHD 22-02-005 Rev 04/19/12 <br />