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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.org/ehd <br /> RETURN TO CONI LIANCE 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 EHb staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. i <br /> s <br /> For. this certification t0 be COm pletlr the operator of the site must include: <br /> • A statement documenting what corrective actions Were taken or will betaken for each violation <br /> • Copies of sample results/manifests/training records%other appropriate paperwork, avid/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: Inspected By: <br /> Facility Address: 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 information to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3. lam 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: 0,9W7' < E.J.!/rK�st:✓ Title: �"'a�.e »r ,rac �i�,yam <br /> Signature: Date: ��, , 9 ,2pO <br /> EHD 22-02-005 Rev 10/09 <br />