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06/01/2011 23:15 209 6552?9 ABC FOOD MART PAGE 01/01 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 B_Main St., Stockton,CA 95202-3029 <br /> Telephone. (209)468-3420 Fair:(209)468-3433 Web.www.sigov.org/ehd <br /> 1 <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 lolations noted in the attached Inspection Report or Continuation Form, or <br /> disputes to any violation;,are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specific in the Inspection Report. <br /> Note: All ERD staff tiz ie associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate($105). <br /> For this certifica on to be complete,the operator of the site must include: <br /> • A statement dociumenting what corrective actions were taken or will betaken for each violation <br /> • Copies of sanapl results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying correct ons <br /> • Operator's certification <br /> Inspection Date: ICZ 7 Inspected By: S �R�y 001--6) <br /> Facility Address: 713 A✓ -'C Iia RA b 0 S i EPA IIID#: 64L o 00-36 3-S�2 a <br /> S r c 14 -TQa-j C/+ q sa-a <br /> I certify under penalty of law that: <br /> 1. I have corrected t4e 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 VIOLATI N and I believe the information to be true, accurate, and complete: <br /> Photos Pap ork Statement <br /> 3. 1 am authorized t submit this certification on behalf of the Respondent. <br /> 4, l 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: , � SJ i /V Title: (_1) <br /> Signature: Date: <br /> EHD 22-02-005 Rev 10-07 <br />