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T10isi Son Joaquin County IV <br /> EnVironmentat Health Department <br /> a5,7 /2'c)t E5 1868 East Hazelton Avenue, Stockton, Califomia 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgoy&LqLqW <br /> I oAY 11 2015 <br /> RETURN TO i�OMPLIANCE CERTIFICATION <br /> ;=Nk IRONMENTAI <br /> Any MINOR violations noted in the'Notice to COmpy in the attached Inspection Report must be come within 30 dam of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Healthparlml intaddress; <br /> the top of this form within 30 days of receipt of the Inspection Report HSC 26404.1.2(c)(1) <br /> AM cormgVgl2a to other violations noted in the attached Inspection Report(IR)or Continuation Form, or disputes to any <br /> violations, are to be submitted using this certifl�alon and returned to EHD within M-daya unless otherwirw specified in the <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff fame assocla*d with failing to comply by the above noted dates will be <br /> billed at the current hourly ra*. <br /> For thiscertification to be corhplete, the operator of the site must include: <br /> A statement documenting what correc4 I ve actions were taken or will be taken for each violation <br /> Copies of sample resufWman(fests/tra1)nlng records/other appropriate paperwork,and/or photos verifying corrections <br /> Inspection Date: April 23, 2015 <br /> Inspected By; STACY RI ERA <br /> Facility Address., 4100 E FREMON-11; ST STOCKTON EPA IIS <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 exemia ed the folloWl'Ing documentation submitted as proof of compliance FOR EACH MO TION <br /> I believe the information to be true,accurate,and complete, <br /> 2h6to5 Paperwork / Statement <br /> 3. 1 am authorized to submit this cert cation on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the postc ibility of a fine and/ <br /> imprisonment for known vi lations. (HSC 2619 <br /> Name* —Ttle- <br /> Signatu Date: <br />