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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.ory/ehd <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 616'submitted to the I <br /> Envirorimeiytal 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(IR)or Continuation Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 30 dans <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 be <br /> billed at the current hourly rate. <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/manifeststtraining records/other appropriate paperwork, and/or photos i <br /> verifying corrections <br /> e Operator's certification <br /> Inspection Date: S 2,' 1 Inspected By: L t c.tll ". <br /> Facility Address: t4 0 ro l<e EPA ID#: C <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. 1 have personally examined the following documentation submitted as proof of compliance FOR ! <br /> EACH VIOLATION and'I believe the informs ' n 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: 4 (., Title: lot—Q-\ g- C_-4— Al r� � <br /> Signature: <br /> EHD 22-02-005 Rev 10/09 <br />