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San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton.Califomia95205-6232 <br /> Telephone.(209)468-3420 Fax.(209)468-U33 Weir wm.§jW—v.om/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the'Notice to Comply"in the attached Inspection Report must becoffected within 30 days of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EI-10)address <br /> the top of this form within 30 days of receipt of the Inspection Report HSC 25404.1.2(c)(1) <br /> All corrections to other violations noted in the attached Inspection Report OR)or Continuation Form,or disputes to any <br /> violations,are to be submitted using this certification and returned to EHDw!tNn 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 not 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 results(manifestsftraining recti other appropriate paperwork,anchor photos verifying correction: <br /> Inspection Date: Inspected By: /"A',T,` N11-1 <br /> A <br /> Facility Address. 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 /> I believe the information to be true,accurate,and complete: <br /> Photos—�LPape rwork 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 andfi <br /> imprisonment for known violations- (HSC 25191) <br /> Name: lem-k WD Title. <br /> Signature: Date. (,e - <br /> JUN 0 3 ?016 <br />