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SAN J AQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E. Main St. Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 F (209)468-3433 Web:www.sii~ov.or <br /> RETURN TO COMP IANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to mply" 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 attched Inspection Report or Continuation Form, or <br /> disputes to any violations, are to be submitted usi g 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 failir fail' g to comply by the above noted dates will be billed at <br /> the current hourly rate ($115). a <br /> L3ude: <br /> in <br /> For this certification to be compl to the operator of the site must <br /> • A statement documenting what corrective actions were taken or will be taken fott„�4c4 t6144n <br /> • Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections ENVIRONMENTAL HEALTH <br /> • Operator's certification DEPARTMENT <br /> Inspection Date: b Inspected By: <br /> Facility Address: EPA ID#: ,,fL�S-,G <br /> I certify under p natty of law that: <br /> I. I have corrected the violations specified i 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 in rmation to be true, accurate, and complete: <br /> Photos Paperwork V Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. I am aware that there are significant penal les for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: Title: ,pM � <br /> S ignature: Date: <br /> FHD 22-02- 5 Rev 10-0 <br />