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SAN JOAQUIN COUNT( <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> relephbne.(209)468-3420 Fax.(209)408-3433 Web:wwws•-ov.or lehd <br /> IOAC.iW JG-: <br /> =h, <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 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 30 days of receipt of the <br /> Inspection Report. HSC 25404.1.2(c)(1) <br /> Allrections 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'Uthin 30 days <br /> unless otherwise specified in the Inspection Report. HSC 25185(c)'(3) <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 t0 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 records/other appropriate paperwork, and/or photos <br /> verifying corrections , <br /> • Operator's certification <br /> Inspection Date: 112- inspected By:Stacy Rivera <br /> Facility Address: EPA ID#: G. dO�{ v <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mn tloned <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 Information to be true, acc ate,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 a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: JTitle: <br /> Signature: r <br /> Date: <br /> EHO 2202-008 Rev 09111 <br />