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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTt4mENT <br /> 1868 East Hazelton Avenue,Stockton, California 95205-6232 <br /> Telephone:(209)468.3420 Fax:(209)4M3433 Web.www.sjgov.orglehd <br /> RETURN TO COMPLIANCE CERTIFICATION <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 mast be submitted to the <br /> Environmental Health Department(E=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 /> Al corrections to other violatipn5 noted in the attached I nspection Report(I R) or Continuation Form.or <br /> disputes to any viclations, are to be submitted using this certification and returned to E H D wiihin-30 days <br /> unless otherwise specified in the Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with fabling to comply by the above rioted dates will be <br /> Filled at the current hourly rate. <br /> For this certification to be cornplete 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 resultslmanifests/training recordsJother appropriate paperwork,andlor photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: March 13, 2019 Inspected By:Lydia Baker <br /> Facility Address, 16470 CAMBRIDGE BT EPA ID#: <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspectlon Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined the following documentation subrnitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the Information to be true, accurate,and mplete: <br /> FYi.r Ar fO,L i-076, <br /> Photos ` Paperwork�Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4, lam aware that there are significant penalties for submitting false information, including the <br /> passibility of a fine andlor imprisonment for known violations. (HSC 251:91) <br /> Name: K WL!d Title: 1�&44- <br /> Signature: Date: <br /> AHD 2M2-M ReY+MITI 2 <br />