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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,sigov.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 days <br /> unless otherwise-specified in the Inspection Repo' <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 to 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:_ �z/b _ Inspected By: Z!96 X)add <br /> Facility Address: ,6 )77 Wowtg,L_ t4 EPA ID#: ✓,� l <br /> �c-ldf•oo � Gkt 9'5330 <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., . - r;.` '` - <br /> 2, I Have personally examined the fallowing . .puMentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the inforMatibn to be true, accurate, and complete: <br /> c--Photos 'Paperwork C-Statement <br /> �l <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 /> passibility of a fine and/or imprisonment fo'r'k,,6 n violations. (HSC 25191) <br /> � <br /> Name: //�a rntY yEc E-'U Title: <br /> �4 <br /> Signature: Date: 3 o <br /> EHD 22-02-005 Rev 10/09 <br />