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- SANJOAQUIN COUNTY <br /> - - <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Tefephone:•(209)468-3420 Fax:(209)468.3433 Web:www_sjgoyorg/ehd <br /> I <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations note ,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 /> Ali 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. <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 resutts/man'rfests/training recordslother appropriate paperwork, and/or photos <br /> verifying corrections <br /> • O ratoes certification - <br /> Inspection Date:_0 r a—C) c} Inspected By: ;/{ <br /> Facility Address: E�°J1 L� I EPA ID#, <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. 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the infojrmma`tion to be true, accurate, and complete: <br /> Photos r" Paperwork 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 imp 'rsor ant <br /> /for known violations. (HSC 25191) <br /> Name: r.ctk'� ;' 1 r�✓�'it— Title: /V <br /> Signature: Date: i <br /> NY Oma. 7Ne <br /> BTO/ Z00'd OOOZ# L0:60 9002/TZ/90 <br />