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oozasa <br /> SAN JOAQUIN COUNTY RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT Y <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telep.'rone: (209) 468-3420 Fax:(209)468-3433 Web:www.sioov.org/ehd MAY 16 /nil <br /> _ ENVIRO <br /> RMIT/SERVICEg LTH <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 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 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: �� I // Inspected By: Er(CICf14 I/OLN- <br /> Facility Address: RPh' N. 4WC1' Sacra /vo,,f 14PA ID#: CSA-(- cx)o `3/Z. (oS Z. <br /> LL'0 Yf b rr die/ C-4- <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 information to be true, accurate, and complete: <br /> Photos _Paperwork A _Statement �,See_atio'-) <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' H ej w Z LA Title: <br /> � Cf L)LJ N e r- <br /> at <br /> �� <br /> Signature s Date, S///Y /L <br /> S rn Fe ++¢*j 4' 0y, t 2 K 1.r I'r,4 4 Z.4,0e.L) <br /> u��'Ks��r� zxs�Oe�74�� ?e�o.�7` F✓ ��.r �08' — ��a — �a 3— <br /> EHD 22-02-005 Rev 08/08 S�Y� <br />