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Nay. 1. 2014 9: 02aM • • �t� 1 <br /> IED <br /> SAN JOAQUIN COUNTY i <br /> ENVIRONMFiNTAL HFALTH DEPARTMENT MAY 0 1 201¢ <br /> 1858 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone;(209)46$-3420 Pax: (249)468-3433 Web.,www.sjg oy RONMENTAL HEALTH <br /> �DEPARTMENT <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any M1NQR violations noted in the"Notice to Comply" in the attached Inspection Report must be <br /> corrected wlthin 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 /> Inspection Repoli. NSC 2540412(c)(1) <br /> All corrections to other violations noted in the attached Inspection Report (IR) or Continuation f=orm, 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. NSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above rioted 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 /> o A statement documenting what corrective actions were taken or will he taken for each violation <br /> Copies of sample resultslmanifests/training recordslother appropriate paperwork, andlor photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date:� Inspected By:Oaxn ia- e—kap, <br /> Facility Address: I i (M Cod,I EPA IDS; L- L �5 f7 l.. <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection=Report-from the above-mentioned <br /> inspection date. <br /> 2_ 1 have personally examined the following documentation Submitted as proof of compliance FOR <br /> EACH 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. (HSC 25191) <br /> Name: Title-SN <br /> _EhLL �J,j <br /> Signature: S _ Date: t f I` I <br />