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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.org/e <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be <br /> within 30 da 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 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 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD staff time associated with fabling to comply by the above noted dates will be billed at <br /> the current hourly rate. <br /> For this certification t0 be COmpletC 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: 213 '�6-t� Inspected By: Uig 611C 4`6/0"7 <br /> —7 <br /> Facility Address: I P 1 EPA ID#: <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. I have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and 1 believe the information to be true, accurate, and complete: <br /> Photos T , ---Paperwork A 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 /> Name: 6-11 <br /> Title: °r�.� <br /> Signature: <br /> l <br /> EHD 22-02-005 Rev 11/07 <br /> 8E80E9-b60Z VD uO�NDCIS dinb3 alejsunS Wd 6E -�0 800Z-ACN-EO <br />