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r 4 <br />? A�-Tb <br />SAN <br />RECEI <br />,kL HEALTH DEPARTmE Tf <br />600 E. Main St, Stockton, CA 95202-3029 JAM 1. 1 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web; vnKw-siRov.or¢lehd <br />ENVIRONM <br />RETURN TO COMPLIANCE CERTIFICATION <br />QED <br />13 <br />IVT, <br />Any MINOR violations noted in the "Notice to Comply" in the attached inspection Report must be <br />corrected within 30 clays of receipt of this inspection. This certification form must be submitted to the <br />Environmental Health Department (EEM) address at the top of this forut within 35 days of receipt of the <br />Inspection Report. <br />All corrections to other violations noted in the attached Inspection Report or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 3Q days <br />uaiess othenvise specified in the .Inspection Report. <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be bed at <br />the currcut buurly rate (,$125). <br />For this certification to be complete the operator of the site xnust include: <br />• A statement documetttiug what corrective actions were taken or will betaken for each violation <br />Copies of sample zcsults/marufcsts/training records/other appropriate paperwurk, and/or photos <br />verifying corrections <br />• Operator's certification <br />r� <br />Inspection Date: % 1 Inspected By: 7&t x,. 4 /Y - <br />Facility Facility Address:< ---7,'714 C ,c PA ID#:� <br />/ 2 6 <br />1 certify under penalxy of law that: <br />1. T have corrected the violations specified in the ,inspection Report from the above-mentioned <br />inspection date. <br />I 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 />I am authorized to submit this certification oa 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. (TSG 2519 1) <br />Name: <br />EHD 22-02-005 Rev 08/10 <br />Z01To 39v:� <br />QI_I11A ;"WO 3HI-1 H <br />Tate: <br />9L9LC9250Z ST:!: -'T. 6T0Z/T1/T0 <br />