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1 • 001603 <br />I� <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www sig_ oyor,/eM <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violati'on's 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 />Environfiental 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 (IR) or Continuation Form, or <br />disputes o any violations, are to be submitted using this certification and returned to EHD within 30 days <br />unless o terwise specified in the Inspection Report. <br />Note: A4 EHD staff time associated with failing to comply by the above noted dates will be billed at <br />the curreut hourly rate ($98). <br />F'Or this certification t0 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 />Date: 7-J-;� -OR Inspected By:4 yu � } caocVS <br />Facility ddress:y �AR 4 ,h pje� EPA ID#: C& Q Q0 z_y_ <br />jtor.}`toNl e4. q � <br />I certi under penalty of law that: <br />1. I <br />2. I <br />3. I <br />4. I <br />corrected the violations specified in the Inspection Report from the above-mentioned <br />ion date. <br />personally examined the following documentation submitted as proof of compliance FOR <br />VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos Paperwork _Statement <br />authorized to submit this certification on behalf of the Respondent. <br />aware that there are significant penalties for submitting false information, including the <br />bility of a fine' and/or imprisonment for known violations. (HSC 25191) <br />Title: (& U#2k�4 <br />Date: ,P i n <br />EHD 22-02J005 Rev 11/07 <br />