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�..� SRN JQAQUIN COUNTY <br /> } <br /> ENVIRONMENTAL HEALI H' DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)463-342.0 Fax; (209)468-3433 Web:www.sigov.ora/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br /> corrocted within 30 days of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department (EHD) address at the tqp of this form 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 to be completethe operator of the site must include: <br /> • A statement documenting what corrective actions vypre 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: ori/o (o _ Inspected By: T ,w t, M <br /> Facility Address:J*'5F-. Llifr. !2J Lai al X330 EPA ID#:_Cjg <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 /> f <br /> 2: 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information tQ be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3:'`1"am authorized to subfnit this certification on behalf of the Respondent. <br /> ,*-"' 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: LL6V-),\ Title: �fkv)r- . ttl,5 v ' <br /> Signature Date: <br /> AHD 22'=02005 Rev 10109 <br />