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�,. SAN JOAQUIN COUNTY <br /> / ENVIRONMENTAL HEALTH DEPARTMENT J <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.wWehd <br /> 2906 6EP 12 IM 11: 2 <br /> C ' , i <br /> RETURN TO COMPLIANCE CERTIFI"� NT'r <br /> kE;,L ill ;Chl <br /> DEP h� <br /> RTHENT <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(EM)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 results/manifests/training recordslother appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification /7 <br /> Inspection Date: �/l 40 Inspected By: r l© <br /> Facility Address: z111,ii EPA ID#: pp 0 ,3 o, 2-5-2-t <br /> I certify under penalty of law that: <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 VIOLATION and I believe the information to be true,accurate, and complete: <br /> V/ Photos- Paperwork Y-/acStatement <br /> 3. I am 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 <br /> oof_aa fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: S Title: <br /> Signature: Date: , <br />