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SAN JOAQUIN COUNTY IN CHIVED ii <br /> ENVIRONMENTAL HEALTH DEPARTMENT APR I' <br /> 600 East Main Street, Stockton, CA 95202-3029 , 9 ��I� <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.a 1 ENT HEALTH <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 I <br /> Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the <br /> Inspection Report. <br /> i <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 /> i <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/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: -S A—M/ _ p p Inspected By: <br /> Facility Address: MAi/ll S'7' 3A= -z2j/EPA ID#: CA,1_000 a K( 661 <br /> I certify under penalty of law that: <br /> i <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have Nerscnaiiy examinei the blowing documeniation ;;ubmitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete: <br /> Photos Paperwork Statement j <br /> I <br /> i <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:4 ENkZ RN Title: 41 rel./ <br /> s <br /> Signature- Date: 01 O <br /> i <br /> EHD 22-02-005 Rev 10/09 RETURN TO COMPLIANCE <br />