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i - E4 San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue,Stockton, California 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web; .siaov.or-Q ehd <br /> COMPLIANCERETURN TO CERTIFICATION <br /> Any MINOR violations noted In the"Notice to Comply"In tate attached Inspection Report must be corrected within 30 dove 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, HSC 25404.1.2(c)(1) <br /> All 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 be taken for each violation <br /> Copies of sample resuitslmanifeststtraining recordslother appropriate paperwork,andfor photos verifying <br /> corrections <br /> Inspection Date: August 20, 2014 Inspected By: STACY RIVERA <br /> Facility Address: , TRACY It�b:t5 lAne 1\IC 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 inspection date, <br /> 2. 1 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 A aperwork "' Statement <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 /> andfor Imprisonment for known violations, (NSC 25191) -- <br /> Name; 1 (4 eV._ 15 A 7-&, -- Title: I/ia,(UO X OF 6Ny� 'RV <br /> Signature: 'Z Date <br /> E <br /> I <br />