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San Joaquin County" <br />Environmental Health Department> <br />1868 East Hazelton Avenue, Stockton, California 95205-6232JTlk_ <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />.i <br />RETURN TO COMPLIANCE CERTIFICATION <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 />at 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 EHD within 30 days unless otherwise specified in the <br />Inspection Report. HSC 25185(c)(3) <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be f='. <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 <br />corrections <br />Operator's certification <br />Inspection Dater January 11, 2016 Inspected By: Elena Manzo <br />Facility Address: 1097 YOSEMITE AVE CERS ID: 10180561 <br />�au w. <br />I certify under penalty of law that: <br />1. 1 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. F R E H VIOLATIO <br />and I believe the information to be true, accurate, and complete:' <br />Photos _Paperwork L' Statement <br />3. 1 am authorized to submit this certification on behalf of the Respondent. <br />,t „s <br />M <br />4. I am aware that there are significant penalties for submitting false information, including the possibility of a fin; <br />and/or imprisonment for known violations. (HSC 25191) <br />4�0�6Va1;� lf�4 'SALT <br />Name:Title: 0(,d /�/ L a- <br />Signature: �'Date: 7:�''" r <br />j <br />f� -elm <br />A t <br />Ty <br />P <br />'§-.fid <br />