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0 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL.HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sigov.org/ehd <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. HSC 25404.1.2(cXl) <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. HSC 25185(cx3) <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 results/manifests/training recordslother appropriate paperwork,and/or photos <br /> verifying corrections <br /> • <br /> Operator's certification <br /> Inspection Date: / /%L Inspected By:StaCy Rivera <br /> Facility Address;_ !y fJ r tt1 EPA ID#; CA0 tt�FIE 7 19 7cl <br /> 1 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 <br /> II believe the information to be true, accurate, and complete: <br /> X_ Photos---X Paperwork v 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 ajfin-e and/or imprisonment for known violations. (HSC 25191) <br /> y- <br /> Signature: e K Date; <br /> EH0 2202-W5 Rev 0W11 <br />