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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.sigov.org/ehd <br /> RETURNLIANCE CERTIFICATI <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 25404.12(c)(1) <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. HSG 25185(c)(3) <br /> Note: All END 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 operatorof 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 /> * <br /> Operator's certification <br /> Inspection Date:August 7, 2013 Inspected 13y:Garrett Backus <br /> Facility Address:3003 E {dammer Large EPA ID : CAL000082040 <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I 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 t� Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. I am aware that there are significant penalties for submitting false information,including the <br /> possibility of a fine and/or imprii�s{{onment for known violations. (NSC 25191) <br /> Name: P_F,I VAWo Title: ANK- <br /> Signature: Date: -2 <br /> EHD 22.02-005 Rev 04/19/12 <br />