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t <br /> 06/02/2015 6:57 kl FAX 2095994265 �i nt30'&/040& <br /> San Joaquin County <br /> Environmental Health Department <br /> 1860,a,W Hazelton Avenue,Stockton, California 95205. 232 <br /> rerephone.(209) -3420 :(209)468-3433 web.mM,§j9S&,2ra/ehd JUN 2 92015 <br /> t <br /> RETURN TO COMPLIANCE CERTIFICATION ENVIRONMENTAL <br /> rk���F� <br /> Any wMINQR viogtrons noted in the"Notice to Compir in the.attached Inspection Report must be gQrr Athinof <br /> receipt of this inspection, This certification form must be submitted to the Environmental Health Department(1 HO)address <br /> the top of this form within 30 days of receipt of the Inspection Report HSC 25404.1:2(c)(1) <br /> All==ris to 2ftia violations noted in the attached Inspection Report(IR)or Continuation}Form,or disputes to any <br /> violations,are to be suiimltted using this oertiffoation and returned to EHD W_0,hja.,jQjM unless otherwise specified in the <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All EFT staff time associated with failing to comply by the above noted dates .I <br /> billed at the current hourly rata. <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 betaken for each violation <br /> Copies of sample results/manifeststtreinIng recordslother appropriate paperwork,and/or photos verifying corrections <br /> Inspection Date: May 14, 2015 inspected By: ELENA MANZ <br /> Facility Address: 1 501 N JACK TONE Fla RIPON BPA ID: <br /> 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 exarninerd the following documentation submitted as proof of c mprianc€FOR EACH VIOLATION <br /> I believe the information to true,,accurate,and complete: <br /> --Photos aperwork14--statement <br /> 3. 1 am authorized to subunit 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 and/ <br /> imprisonment for known violations, (HSC25191) <br /> Name: Title: <br /> Signature: 17 e z 11 <br /> ��—. <br />