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03/07/2014 12:3162093394684 8 haol /003 <br /> V L101 <br /> Vt: <br /> 'D <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENrAL HEALTH DEPARTMENT - MAR 0 7 2014 <br /> �868 <br /> 1668 East Hazelton Avenue,Stockton,California 95205-6232 <br /> East <br /> telephone:(209)468-3420 Fax:(209)4658-3433 Web.www. aMoIRONMENTAL HEALTH <br /> DE TM�T <br /> ilETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violatiOns noted in the"Notice to Comply,in the attached Inspection Report fft:ust be <br /> corrected within 30,days Of receipt of this inspection. This certification form must be submitted ubmitted to the <br /> mental Health Department(EHD)address at the top of this form within 30 days of receipt of the <br /> Inspection Report, ';l-18C 26404.1,2(c)(1) <br /> All corrections tai gther violations noted in the attached Inspection Report(IR)or Continuation Form,or <br /> disputes to any violklOng, are to be submitted using this Certification and returned to r=-HD 1ui_thin,30 days <br /> unless otherwise specified in the Inspection Report. HSC 26185(c)(3) <br /> Note: All EHD stiff time associated with failing to comply by the above noted dates w[Ij be <br /> billed at the current hourly rate. <br /> For.this certification to be completetheoperator of the site must incl We: <br /> • A statement d1cumenting what corrective actions were taken or will betaken for each;violation <br /> • Copies of sample results/manifests/training records/other appropriate Paperwork, andhior photos <br /> verifying corrections <br /> • Operator's certification <br /> J <br /> Inspection Date: J, Inspected By: <br /> Facility Address: <br /> EPA ID#: <br /> I certify underP9 nalty of law that. <br /> I I have corrected the violations specified in the Inspection Report from the above-m6ntioned <br /> inspection date. <br /> 2. 1 have persTally examined the following documentation submitted as proof of compliance FOR <br /> EACH VI0Lj%TI0N and I believe the information to be true,accurate,and complete: <br /> J <br /> -Photos aperwork VeSiatemen <br /> t <br /> 3. lam authorited to submit this certification on behalf o thi-ffesPondebt. <br /> 4. lam aw6reffiat there are significant penalties for submitting false information, including the <br /> possibility ofl.a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name. Title: <br /> Signature: <br /> Da <br /> EHO 2M2-005 Rev 04/1911 2 <br /> Ao Mix, <br />