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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue,Stockton,California 95205-6232 �? <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.crq/ehd <br /> r. <br /> is <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 /> t <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 /> I <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 <br /> Inspection Date:JUIy 11, 2013 Inspected By:Garrett Backus <br /> Facility Address:655 W Clay Street EPA ID#: CAL000207533 <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete: <br /> Photos Paperwork _Statement <br /> 3. lam authorized to submit this certification on behalf of the Respondent. <br /> 4. lam aware that there are significant penalties for submitting false information,including the <br /> possibility of a finAze <br /> e and/or imprisonment for known violations. (HSC 25191) <br /> Name e_\j vedo Title: EjV,/dn1Ao,J{rt(A4_A1WV1 <br /> Signature: / Date: q <br /> EHD 22-02-005 Rev 04/19112 <br /> i <br />