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SAN JOAQUIN COUNA y <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East ain <br />-3029 <br />Telephone: (209) 468-3 0 ,F=ce(209) 468-3433 Web. ' ov_ eh <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached inspcction report must be <br />wrrected within 30 da s of receipt of this inspection. This certification form, must be submitted to the <br />Envim <br />ronental Health Deparirnent (EHD) address at the top of this form within. 35 days of receipt of the <br />inspection report. <br />All corrections to other violations Muted 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 60 days <br />unless otherwise specified in the TR., <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 resultsicuanifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: g�__ —� <br />_ Inspected By:Ad,�_, , eL�%� , <br />r� <br />Facility Address: I�-ONFGAS &FOOD EPA ID#:_2 <br />w. <br />I certify under penal yv CY CA 95376 <br />ullath <br />1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. I have personally examined the following documentation submitted as Proof of compliance FOR <br />EACH VIOLA FION and I believe the information to be true, accurate, and complete: <br />photos V Paperwork (/ Statement <br />3. 1 am authorized to submit this certification un 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/ori nsonve�ment for own oXations {HS 25191} <br />rr , <br />ame: U <br />Title.- <br />Signature: Date: <br />Q <br />EHD 22-02-005 Rev 05/07 <br />TCJ/T0 :19Vd QOOd Sd0 3NO a 9L9L6E860Z ZT:00 L00Z/L0/60 <br />