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r <br />L <br />0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 fax: (209) 468.3433 Web: www.sIgov.oro/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(c)(1) <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 des <br />unless otherwise specified In the Inspection Report. HSC 25185(c)(3) <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 recordslother appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: 12/4/// Inspected By:Stacy Rivera <br />Facility Address: 32c, WyY 0a SiuclLTo O EPA ID#: C& D 000 & 31 S D1 <br />I certify under penalty of law that: <br />1. l 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 t/ Paperwork Statement <br />3. lam authorized to submit this certification on behalf of the Respondent. <br />4. lam 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 />Date: /) /// / / <br />EHD 22-02-005 Rev 09111 <br />