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Wtian Joaquin t:ounry <br /> rivironmental Health Department � <br /> 1868 East Hazelton Avenue,Stockton, California 95205.6232 <br /> Telephone:(209)468-3420 Fir:(209)468-3433 web.vrtW.gjgo .owlehd MA J 2 3 2015 <br /> RETURN TO COMPLIANCE CERTIFICATION ;._=NVIRONMENTA) . <br /> H�0 T+.1i�c0e0,rVrN1-r <br /> Any MINOR violations noted in the"Notice to Comply"'in the attached Inspection Report must be corrected wig b� 0`days`b -'' <br /> receipt of this irlspecticn. This certification form must be submitted to the Environmental Health Department(EHD)address <br /> at the trip 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 <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 betaken for each violation <br /> • Copies of sample results/manifestskmining recordslother appropriate paperwork,and/or photos verifying <br /> corrections <br /> Inspection Data: February 12, 2015 Inspected By: ELENA MANZO <br /> Facility Address: 1234 E YOSEMITE AVE, MANTECA EPA ID: <br /> 1 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, t have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information to be true, accurate,and complete: <br /> Photos Paperwork Statement <br /> 3. 1 am authorized to submit this certisfication on behalf of the Respondent <br /> 4. 1 am aware that there are significant penalties for submitting false information, Including the possibility of a fine <br /> and/or im ' ment for known violations. (HSC 25191) <br /> Name: 7V7 IV I1`� c� Trtfe:V5� (joMPwAKc� o�2�IKt�v2 <br /> Signature_ Date: az V5 X15 <br />