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SAN JOAQUIN COUNTY <br /> • ENVIRONMENTAL HEALTH DEPARTMEt <br /> 600 East Main Street, Stockton, CA 95202- 9 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sioov.org/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to Comply" in the attached Inspectiop 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 Report. <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 of$105 (beginning 8/1109 the hourly rate will be $115). <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: -3 Inspected By: S l l /f7i,f <br /> i Facility Address: �D(4i , K.' m�I L' �r_dA ftPA <br /> I certify under penalty of law that: B <br /> 1. I 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 VIOLATION and i believe the information to be true, accurate, and complete: <br /> Photos Paperwork 1�� Statement <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 /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: �aa� (; z 6 Idt` �(; r°i r Title <br /> Signature Y' Date: <br /> hi IL <br /> r <br /> JUN 2 0 aril <br /> EHD 22-02-005 Rev 08/09 <br /> i <br />