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-?:C4''..' c. . 'a.' ,•!=.<.§y e"--x'�.-ei"'�,w . ^'�='^..." a"C�¢2wg—"T,., 'I'r'(i'. iF.'' . .S'.r, ,- .. ,. <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT *400 <br /> 304 East Weber Avenue, 3'd Floor, Stockton, CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209 - 433 web:www�sis< v qr <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 violations noted in the attached Inspection Report(1R) er Continuation Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to;EHD within 60 days <br /> unless otherwise specified in the 1R. <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: Ll—O Inspected By: <br /> Facility Address: ��� Lel I%r/�f �i EPA ID#: e-A j_ 091 0 2204 311 <br /> I certify under penalty of law that: <br /> L I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> I 2. I have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete: <br /> Photos--k,—Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. I 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: M 11, 14 asrvut. "Title: <br /> Signature: Date: —) Li- 4)7 <br /> EHD 22-02-005 Rev 12-04 <br /> Td WdTE:ET S00Z ZS 'unf L9Ot,29t76OE: 'ON XUA SNOISSIWSNUZIl Q33dS HOIH: WONd <br />