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RECEIVED <br /> San Joaquin County DEC 17 2015 <br /> (Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 ENVIRONMENTAL HEALTH <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web.WC .sj ov.ora/ehdE WMISER sI E <br /> RETURN TO COMPLIANCE CERTIFICATION , <br /> IFICATION <br /> i <br /> Any MIU( $violations noted in the"Notice to Comply'in the attached Inspection Report must be corrected within 30 dates,of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHO)address <br /> the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All oorrec ons to other violations noted in the attached Inspection Report(IR)or Continuation Porm, or disputes to any <br /> violations, are to be submitted using this certification and returned to EHDwithiLl 4 days unless otherwise specified In the <br /> Inspection Report HSC 25186(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noied dates will be <br /> billed at the current hourly Irate. <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/manifestsrtraining records/other appropriate paperwork,and/or photos verifying corrections <br /> Inspection Date: November 16, 2015 Inspected By: FATINAH ZAREEF <br /> Facility Address: 4987 WEST LN STOCKTON EPA IQ,. 1 G 0-944 <br /> I certify under penalty of law that: <br /> GM%\t® O f C <br /> 1. l the violations specified in the Inspection Report from the above-mentioned i0spection date. <br /> 2. 1 personally examined the following documentationotpubmitted as proof of compliance FOR EACH VIOLATION <br /> i <br /> V" Photos ✓ Paperwork teme <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent- <br /> 4. <br /> espondent4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine and/ <br /> imprisonment for known violations. (MSC 25191) <br /> i <br /> Name: Title: RV®`r 0t' <br /> signatu Date: 2 -1 <br /> 80180 3!DVd 3NV1 1S3M Z1717099660Z tZ:ZZ 5I0Z1170/Zt <br />