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o...: r:pq)ha;K•�iy3!n-'n .:.. ... .:.'R'iaS_rlP.dpi?P*^•,x.�T�^�'�., +C'�'.NMXF?'si^S7t,'M7?c^"ow#rt."'�.:+,M.+p..y,+?}x ,,�,��.��.«..p.rx, �yry�ey"ea;v <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 85202-3020, <br /> Telephone: (209)468-3420 w Fax: (209)468-3433 Web:wsnoV.org/ehd <br /> Lj <br /> — ., <br /> s <br /> RETURN TO COMPLIANCE CERTIFIC/ffWWR 52010 <br /> 2 2 <br /> N J0', L"q COUNTY <br /> ENknp <br /> Any MINOR violations noted In the "Notice to Comply" In the attached InspectdAFRappt ,pp <br /> corrected within 30 days of receipt of this Inspection. .This certification form must be submrtt�aLd to the <br /> Environmental Health Department (EHD)address at the top of this fort within 30 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 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. <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For 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/tralning records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification - — <br /> Inspection Date: O ZL(, i O Inspected By: <br /> tCXtAA <br /> FaclloAddress: �:Noo N 6y 0-r T-`jPAID#: <br /> I certify under penalty of law that; <br /> 1. I 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 Informatlon 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: �"�cn.r rn wT t to sa-41�A Title: U �c <br /> Signature: -- Date: c:::) .3rQ 3 <br /> i <br /> EHn 22a2.00S ReV 10/09 <br /> 1 '4 XH3 13rN3SH1 JH W89T :2 0102 92 JeW <br />