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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 Far.(209)46✓i3433 Web:w sieov.ordehd <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 days <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 to be complete the operator of the site must induce: <br /> • A statement documenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample resultsfmanifests/tmining records/other appropriate paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date:1142� Inspected sy:Stacy Rivera <br /> Facility Address:>.�73 0-Fq- Aeo.EPAIDN: <br /> �lS�J <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 1 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. lam aware that there are significant penalties for submitting false information,Inducing the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: Title:.� v2, <br /> Signature: Date: p-/O-/. <br /> oa aaaarsa.vram <br />