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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..s' Qv.or /ehd <br />CERTIFICATIONRETURN TO COMPLIANCE <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br />Environmental Health Department ( HD) address at the top of this form within 30 days of receipt of the <br />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 <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br />unless otherwise specified in the Inspection Report. HSC 25155(c)(3) <br />Note: All EH I staff time associated with failing to comply by the above noted dates will be <br />billed at the ct;rrnt hourly rate. <br />For this certification to be completethe operator of the site must include: <br />• A statement r.t�cu m:�r;tincg what corrective actions were taken or will be taken for each violation <br />• Copies of sample re. ;JItsfmanifestsltraining recordslother appropriate paperwork, and/or photos <br />verifying corrections <br />. Operator's certification <br />Inspection Date: August 6, 2014 <br />Inspected <br />Facility Address: ' :>>° 1 Jackson S_.: Escalon EPA lCt#: CAL000286266 <br />I certify undor ,-erallv of law that: <br />1. 1 have cora t d lhn violations �-)ecifi ,d in the Inspection Report G <br />inspection sir .:. BVE D <br />BE <br />2. 1 have personally examined the following documentation submitted as pro(AL4cbrjj0We FOR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete <br />Photos Paperwork MENTAL HEALTH <br />DEPARTMENT <br />3. 1 am authorized to submit this c, �tftation on behalf of the Respondeat. <br />4. 1 am aware that there are significant penalties for submitting false information, including the <br />possibility of innp,=>onament for known violations. (HSC 25191) <br />Nam �. I �. � _ ` Title: <br />Signature. �.� � � � � � e _ �!' Gate: <br />EHO 22-02-005 Rev 0411 W' <br />