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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.sjy.org/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 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. <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 dayl <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 /> bllled at the current hourly rate. <br /> For this Certification to be Compiete 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 /> /111 <br /> Inspection Date: v Inspected By: <br /> 5 <br /> Facility Address: <br /> G/ f' �'�"'� C' EPA ID#: �U�D J <br /> I certify under penalty of law that: <br /> 1. 1 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 VIOL-ATION and I believe the Information to be true, accurate, and complete. <br /> Photos Paperwork Y Statement <br /> 3, I 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 /> PF <br /> Name: " ' or Title: <br /> Signature: <br /> Date: <br /> EHD 22.02-005 Rev 10/0e <br /> 8£80£9b60Z dJ uoj��ojs dinb3 ajeisuns Wd £O ll 0602 udV 60 <br />