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Rx Date/Time 5EP-15-2005(THU) 17:26 2094650723 P.001 <br />09/15/2005 14:47 2094650- TOYS R US DC 58 PAGE 01/01 <br />SAN .IOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3'd Floor, Stockton, CA 95202.2708 <br />Telephone: (209) 468-3420 lax: (209) 468-3433 Web: www.sjgov.or /g ehd <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 must be submitted to the <br />Environmental Health Department (EHD) address at the top of this form within 35 days of receipt of the <br />inspection report. <br />All corrections to other violations .noted in the attached Inspection Report (ZR) or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 60 days <br />unless otherwise specified in the IR. <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: w -O.5- Inspected By: s" �2� <br />1K+ <br />Facility Address: ldua- EPA ID#: C QL6,m n <br />I certify under penalty of law that: <br />I have corrected the violations specified in the Inspection Report from the 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 information to be true, accurate, and complete: <br />Photos Paperwork Statement <br />3. I am authorized to submit this certification 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 violations. (HSC 25191) <br />Name: /M/ �Sf���C — hw /_44"q, �1pTi.tl.e: i!/irOnM� % Cdn1P��Gkct PW <br />azure: 14 11 Date: y If j 5 <br />EHD 22-02-005 Rev 12-04 <br />