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»' San Joaquin County <br />Environmental Health Department <br />1858 East Hazelton Avenue Stock a L� <br />,PR 16 2016 <br />RETURN <br />CERTIFICATION, <br />Any t Dviolations noted in the "Notice to Comply" in the attached inspection Report must be d wi �n 0 A --of <br />receipt of this inspection, This certification form must be submitted to the Environmental Health Department (EHE D) address. <br />the top of this form within 30 days of receipt of the Inspection Report, HSC 25404.1.2(c)(1) <br />All conections noted in the attached inspection Report (Ili) or Continuation Form, or disputes to any <br />violations, are to be submitted using this certification and returned to EHD wt 30 Ws unless otherwise specified in the <br />Inspection Report. HSC 25185(c)(3) <br />Note: All JEHD staff time associated with failing to comply <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 be taken for eacch violation <br />Copies of sample results/manifests/training records/other appropriate paperwork, arid/or photos verifying corrections <br />Inspection Date* May 173 2016 _ Inspected y: 1=ATINAH ZAREEI` <br />Facility Address: 1612W HAMMER LN STOCKTON EPA tib:_ <br />I certify under penalty of law that: <br />i1=1 have ■ ed the violations r- e♦ j• <br />2. 1 have personally examined the following documentAon submitted as proof of compliance FOR EACH VIOLATION <br />I believe z information to be true, accurate, and mplete; <br />Photos <br />7PIaperwork <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, including the possibility of a fine <br />imprisonment for known violations, (HSC 25191) <br />