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SAN JOAQUIN COUNTY � <br />ENVIRONMENTAL HEALTH DEPARTMENT r ._ <br />is <br />600 East Main Street, Stockton, CA 95202-3029 <br />TNophorw: (209) 468-3420 FAX, (20s3) 488-3433 IMeb: ww-w aov.ora/ahG �� <br />AUG 9 n Inn <br />J, A{ <br />jUliU (� <br />RETURN TO COMPLIANCE CERTIFICATION N`%��t,"� �pNTY <br />FalTtir--;.,. <br />_ ,r3r�FNr <br />Any (AOR, violations noted in the "Notice to c:,ompir in the attached Inspection Report must be <br />oorre= Mthin 30 days of receipt of this inspection. This certification form must be submitted to the <br />Environmental Health Department (EHD) address at the top 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 (1R) 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 bo <br />billed at the current hourly rate ($105). <br />For this Gertif Ccatio 1 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: n D Inspected By: A R is L ACA PIT <br />Facility Address: Q E L6d1 � EPA IEW c-r4L,o 0 0 31 a 2X <br />9 Say 0 <br />I certify under penalty of law that: <br />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 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 />Name: <br />S <br />Date: <br />TO 39Vd A30a d QNd Q TZ9Z696603 6b:30 6662/52150 <br />