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03/07/2014 12:31 2093344684 8 01 /003 <br /> IVED <br /> SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT MAR 0 7 2014 <br /> East ast Hazelton Avenue,Stockton,California 95205.6232 <br /> 868�as <br /> relephom:(209)468-3420 Fax:(209)468-3433 Web.www sig <br /> 0�'�IRONMENTAL HEALTH <br /> EAT <br /> LENT <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 3p ldays 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 IQ er violations noted in the attached Inspection Report(IR)or Continuation Form, or <br /> disputes <br /> to any violbtions, 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 notedi dates will be <br /> billed at current hourly rate. <br /> For this CIS tion to be co <br /> mpletethe operator of the ske must include: <br /> A statement dqcumenting what corrective actions were taken or will be taken fbr eachylolaVon <br /> Copies of sample results/manifestsAraining records/other appropriate paperwork,and4or photos <br /> verifying corrections <br /> Operator's certification <br /> Inspection Date: , Inspected By: <br /> Facility Address:' <br /> EPA ID#: <br /> I certify under §nalty of law that; <br /> p� <br /> 1 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection dbte. <br /> 2. 1 have pe ally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOL.,�TION and I believe the information to be true,accurate,and complete: <br /> _Photos aperwork V'Statement <br /> 3. 1 am authonizi ed to submit this certification on behad of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the <br /> possibility ofl <br /> .a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: t <br /> I<Liot Titter _ <br /> Signature.-_ <br /> Date: <br /> -------------------------------------- <br /> . p. <br /> EHD U42-005 Rev CW19/12 it <br /> 10 : <br /> COL'S <br />