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_ N <br /> ♦ I Ii <br /> San Joaquin County <br /> Environmental Health Department i <br /> 11868 East Hazelton Avenue, Stockton , California 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.ejgov.org/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> I <br /> Any MINOR violations noted inithe " Notice to Comply" In the attached Inspection Report must be cerrrected within 30 days of <br /> receipt of this inspection. This Icertification form must be submitted to the Environmental Health Department (EHD) address ; <br /> i the top of this form within 30 days of receipt of the Inspection Report, HSC 25404. 1 .2(c)(1 ) <br /> E i <br /> All corrections to other violatiens noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br /> violations, are to be submitted ysing 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 tii�ne associated with failing to comply by the above noted dates will be <br /> billed at the currept 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 corrections <br /> I <br /> Inspection Date: Mav �4, 2016 Inspected By : ELENA M /A�NZO _ <br /> Facility Address: 2350 <br /> 0 KASSON RD TRACY EPA ID: MIT A06 ( 70 7s <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 /> i` <br /> E 2. 1 have personally exargined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the informi on to be true, accurate, and complete: <br /> )(Photos Paperwork X.Statement <br /> i 3a lam authorized to submit this certification. on behalf of the Respondent. <br /> I <br /> 4. I am aware that there are signiftcant penalties for submitting false information , including the possibility of a fine <br /> and/or imp"onment fo 1 known violations. (HSC 25191 ) <br /> Name: 1,- 7�f ' / Title: <br /> a <br /> Signature: Date: <br /> � I <br /> I <br /> i <br /> I <br /> i <br /> SEP I I � ; n <br /> ¢ F fko �4r <br /> ke <br /> (� I <br /> I <br />