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FAXED <br /> SAN JOAQUIN COUNTY L a Lr(, - <br /> c� ENVIRONMENTAL HEALTH DEPARTMENT <br /> C� 'd 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> C Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.s' v,or /ehd <br /> RETURN TO COMPLIANCE CERTIFICATIOr""E <br /> GEEL., <br /> 1 <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be <br /> corrected within 3.0 days of receipt of this inspection. This certification form must be submittede <br /> Environmental Health Department(EHD) address at the top of this form within 30 days of receipt off tfig 2014 <br /> e <br /> Inspection Report. HSC 25404.1.2(c)(1) <br /> ENVIRONMENTAL HEALTH <br /> All corrections to other violations noted in the attached Inspection Report(IR) or Continuatlon[� 61FTMIENT <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 28185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted 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/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: �� �.^1 Inspected By:Elena Manzo <br /> Facility Address:— { + �.I <br /> 'WW <:,-kQst� EPA ID#: CA�qg�o sit R ` <br /> �I certify under penalty of law that: <br /> (t 1. J I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 0ave personally examined the following documentation submitted as proof of compliance FOR <br /> CH VIOLATION and I believe the information to be true, accurate, and complete: <br /> Photos Paperwork 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 <br /> possibility of a fine and/or imprisonment for known violations. (HSG 25191) <br /> S <br /> Name: r Title: -t—-�L-(-Prr <br /> Signature: Date: <br /> �/ EHE)22.02-005 Rev 04119/12 <br />