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,T- r r <br /> J <br /> . . - � <br /> SAN JOAOU|NCOUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 8OOEast Main Street, Stockton, CA 95202-3029 NOV ~ <br /> � � <br /> Telephone: (2Ug)468'342OFax: (20S)4G8'3433Web: <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> AnyMINORviu|ationonotedinthe ^Noticeto <�ornp\y'' intheadmchad |napectionRupu� rnuotbo <br /> corrected within 30 days f receipt of this inspection. This oa�ifioa�ion form must be submitted to the <br /> Environmental Health uepo ` ' <br /> Department (EHO> address at the top of this formwithin 30 days of receipt of the <br /> Inspection Report. <br /> noted inthe a#ached |napecdonRepo� (|R) orCnnhnuadonForrn' u/ <br /> disputes to any violations, are to' besubmitted using this certification and returned toEHD within 30 days <br /> unless otherwise specified inthe 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 to be completethe 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: \(D\��kc) Inspected By: <br /> - <br /> Facility Address: EPA ID#: <br /> I certify 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. 1 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. 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 /> Signature: Dat 0 2,-7 <br /> cxuo'02-005Rev 10109 <br />