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11&Ull lYf i.V1Y L-1."u 11.IVd VI K-vt%W1 I I MUL ULf V.J <br /> C. !AN 14 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue,Stockton,Galiromia 96205-6232 <br /> Telephone:(209)4M3420 F= (209)468-3433 Web:MW.siaov.orpfand <br /> . RECIE061VED <br /> RETURN TO COMPLIANCE CERTIFICATION JAN 2 31,2014 <br /> Any M1 OR violations noted in the"Notice to Comply"in the attached Inspection Report must <br /> corrected within 30 days of receipt of this Inspection. This certification form must be submitted to AW*DEPARTMENT <br /> Environmental Health Department(EHD)address at the top of this form within 30 days of receipt of the <br /> Inspection Report. HSC 25404.1.2(c)(1) <br /> All correp(igns 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 dans <br /> unless otherwise specified In the InspecUon Report, HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this cei if cation to be complete the operator of the site must include: <br /> e A statement documenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample resuitslmanifestsft fining records/other appropriate paperwork,and/or photos <br /> verifying corrections <br /> « Operators certification <br /> Inspection Date: Jam. t li-A inspected By:Elena Manzo <br /> Facility Address: i © v. i w , ,+ EPA ID#:_ <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 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 Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. f am aware that there are significant penalties for submitting false information,including the <br /> possibility of a fine andlor imprisonment for known violations. (HSC 25191) <br /> Name: Title: <br /> Signature: Date: <br /> EHD 22-02-005 Rev 04119112 <br />