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San Joaquin CountY <br />EnvironmentalHealthDepartment <br />RETURN1868 East Hazelton Avenue, Stockton, California 95205-6232 <br />TwWhone.- (209) 468-3420 Fax., (209) 468-3433 Web: MMA190—Y. MAW <br />TO COMPLIANCETIFIC TI �, —V <br />Any MI violations noted in the 'Notice to Comply" in the attached inspection Report must be gprr w' � 0 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. MSC 25404.1.2(c)(1) <br />All torr on o e of noted in the attached Inspection Report (IR) or ContlnuO)n Form, or disputes to any <br />violations, are to be submitted using this certification and returned to EHD wi t 3p 4 dates 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 tho'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 a;Rch violation <br />Copies of sample results/manifests/training re=ds/other appropriate paperwork, and/or photos verifying co ons <br />Inspection pate: May 09, 2017 Inspected By:, VICKi MCCARTNEY <br />PAr*ility Address_ 1612 VII HAMMER LPI, STUCKTON CERS ID: 10181241 <br />1. 1 have corrected <br />., nviolations <br />specifiedin the InspectionReport above-mentionedinspectiondate. <br />- personalty examined following documentation sue -r as proofof s r FOR EACH VIOLATION <br />and I believe the information to be true, accurate, and complete: <br />Photos '.. r <br />3. 1 am authorized to submit this certification on behalf of the Respondent. <br />4. 1 am aware that there are significant penalties for submitting false information, intruding the possibility of a fine and <br />imprisonment for known violations. (HSC 25191) <br />Nate: A - _ L- S- mow. Tme. <br />0 <br />ilt <br />s <br />