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�18.1`18/2C1C16 1.3:12 46401K ENVIRONMENTAL HE. i PGE 01 <br /> SAN JOAQUIN COUNTY <br /> ENv1RONMENTAi,.HEALT14 DEPARTMENT <br /> 304 East Weber Avenue,3`d Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/chd <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 Departmznt(::HI's)add.ess at the top of tris 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 60 da_y-s <br /> unless otherwise specified in the IR. <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: Te -Q Inspected By: IA!1.0pa Na,dU <br /> Facility Address: • ;AjS EPA Ib#: aA <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally examined th; following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete: <br /> Photos�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 inforirnation,including the <br /> possibility of a fine and/or imprisonment for known.violations. (HSC 25191) <br /> I <br /> .STithe: l�i/+1 iIG �/ <br /> Name:- <br /> Lignature: Date: 102 J- O <br /> EHD 22-02-005 Rev 12-04 <br />