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DollarTree Regional 2099825678 p,2 <br />ENVIRONMENTAL HEAL CH DEPARiMEN 1 <br />1868 East Hazelton Aw.6nue,=�ockton, California 95205-6232 JUL ®�01� <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd ehd <br />WE F4 �1�24mf WT7wVC7 <br />RETURN TO COMPLIANCE CERTIFICATION DEPARTMENT <br />Any MINOR violations noted in the "No#ice to Campiy" in the attached Inspection Report must be <br />corrected within 30 days of receipt of this inspection, This certification form must be submitted to the <br />Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the <br />[nspection Report. HSC 25404.1.2(c)(1) <br />All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <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 25185(c)(3) <br />Note: All EHD staff time associated wifih failing to comply by the above noted dates will be <br />billed at the current hourly rate. <br />F©i^ �EIIS C21'tlflOdtlOn t0 b0 GOI"C1p�C'tC; 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: �D ' 1 /,� Inspected 6y: Sfiacy Rivera <br />Facility Address:/V.1/i/i%/,!ro 'l Wa, 037 EPA ID#: <br />1 certify under penalty of taw that: <br />7. 1 have corrected the violations specified in the Inspection Report from fhe above-mentioned <br />inspection date. <br />2. I have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the infor/motion to be true, accurate, and complete: <br />Photos V Paperwork Statement <br />3. I am authorized to submit this cert <br />ification on behalf of the Respondent. <br />4. I am aware that there are significant penalties for submitting false information, including the <br />possibility of a fine and/or imprisonment for known vialatio�ns�}. (HSC 25191} <br />Name: ��it� i Title:y <br />_ 1 � , <br />�, �t <br />Signature:�LAAAo�rt)Lm 4(it) Date: <br />EHD 22.02.005 Rev 04/18/12 <br />