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• • f <br /> SAN JOAQUIN COUNTY EE <br /> ENVIRONMENTAL HEALTH DEPARTMENT I <br /> 304 East Weber Avenue,3`°Floor,Stockton,CA 95202-2708 II <br /> Telephone:(209)468-3420 Fair(209)468-3433 Web:www si,ov.org/ehd6 <br /> RETURN TO COMPLIANCE CERTIFICATION ' <br /> Any MINOR violations noted in the"Notice to Comply"in the attached inspection report must be [ <br /> corrected within 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 35 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 60 days <br /> unless otherwise specified in the IR. <br /> For this certification to 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 resultshnanifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: f5- �' 5 Inspected. By: &cxva_k"�- yor, lar <br /> Facility Address: 3100 N.AA Ar-f -RA . EPA ID#' Ui,,,660 22 4,! rR�1 <br /> -5+0dC%iVT1 CA <br /> I certify under penalty of law 6t: f <br /> 1. 1 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 VIOLATION and I believe the information to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3. lam authorized to submit this certification on behalf of the Respondent. <br /> 4. I am aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisomnent for known violations. (HSC 25191) j <br /> Dame: Vi e. 5 Title: Pr4d 9k 5i"-V-1y <br /> Signature: i Date: <br /> J' y <br /> EHD 22-02-00S Rev 12-04 <br /> 9 ' d d096 ' ON H01 :6 9001 ' 91 ' Unf <br />