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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: .sjgov.orta/ehd <br /> RETURNCOMPLIANCE C TRIC I <br /> Any MIRM violations noted in the"Notice to Comply'in the attached Inspection Report must beg rro meted Viithin 30 days 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. HSG 25404.1.2(c)(1) <br /> All corrections to other violations noted in the attached Inspection Report(IR)or Continuation form,qr disputes to any <br /> violations, are to be submitted using this certification and returned to EHD with 29-4M unless otherwise specified In the <br /> Inspection Report, NSC 25185(e)(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 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/manifesW&aining records/other appropriate paperwork,and/or photos verifying corrections <br /> Inspection bats: November 16, 2015 Inspected By: FATINAH ZAREEF <br /> Facility Address: 4987 WEST LN, STOCKTON EPA ID: C.Ap %1 Pp(o=L?,4 j <br /> I certify under penalty of law that: <br /> am®\r. o f coir <br /> 1. I hays eaRowed the violations specified in the Inspection Report from the above-mentioned iOspedon date. <br /> 2. 1�11� <br /> Why <br /> personalCy examined the following documentatio ubmitted as proof of compliance FOR EACH VIOLATION <br /> formatle"to t <br /> i <br /> _ Photos Paperwork ✓ 'tat <br /> emen �- . ''® <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant g penalties for submitting false information, including the possibility of a fine and! <br /> imprisonment for known violations. (HSC 25191) <br /> Name: cmA \Navae r Title: �tv``r�ttM2n t <br /> SignaturCDaae: �� (,Z) - <br /> kzj <br /> i <br /> I ' <br /> 80/80 30dd 3NV-1 1S3M 71bb0996GOZ IZ:ZZ 5Z071/00/ZZ <br />