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San Joaquin County HVED <br /> Environmental Health Department MAR 0 2 2016 <br /> 1868 East Hazelton Avenue, Stockton, Califomia95205-6232 <br /> Teiephone:(209) 468-3420 Fax.(209)468-3433 Web:www,sigov.org/e hd �A\���//f {��(f ( �r y /y <br /> E 9 • i�, ONMENTAL <br /> RETURN TO COMPLIANCE CERTIFICATION 'r�✓_�TP,.rT-^ITS <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address <br /> the top of this form within 30 days of receipt of the 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 disputes to any <br /> violations, are to be submitted using this certification and returned to EHDwithin 30 days unless otherwise specified in the <br /> Inspection Report. HSC 25185(c)(3) <br /> (dote: 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 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 paperwork, and/or photos verifying correction! <br /> Inspection Date: Inspected By: <br /> Facility Address: EPA Int <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> I believe the information to be true, accurate,and complete: <br /> Photos �_ Paperwork 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 possibility of a fine and/ <br /> imprisonment for known violations_ (HSC 25191) 1 <br /> Name: C tT ` +MUMS Title:_ OA 1 j1 Ot h�Q� <br /> Signature: Date 3 �-�/ <br />