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• 001603 • <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.sieov.ore/ehd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MIN violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected -thin 30 days of receipt of this inspection. This certification form must be submitted to the <br />Environm tal Health Department (EHD) address at the top of this form within 35 days of receipt of the <br />Inspection eport. <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 oti � ise specified in the Inspection Report. <br />Note: All IIIIEHD staff time associated with failing to comply by the above noted dates will be billed at <br />the current hourly rate ($98). <br />For Nh 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:Inspected By: A ARPLY� ll}-Tvs <br />Facility (Address: `a 2, )[ems EPA ID#:CA` CIAO 3 0 41 <br />I eIfy 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. have personally examined the following documentation submitted as proof of compliance FOR <br />tACH VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos k Paperwork > Statement <br />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 />IDossibility of a fine' and/or imprisonment for known violations. (HSC 2519 1) <br />Date: <br />EHD 2�-02-005 Rev 11/07 <br />