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• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209) 468-3420 Fax: (209)468-3433 Web:www sial ov 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 (I R) 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 t0 be completethe 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 /> r <br /> ection Date: 1 0 �l� BILA- Inspected By:Jeffrey Wong <br /> ity Address: Q S� E t�i AQr <br /> EPA ID#: CR L 60039g`�� <br /> I certify under penalty of law that: <br /> I have corrected the violations specified in the Inspection -Rse ort from j <br /> above 4- i nspection date. ;�� =7/ fes`/ — n 7fJEi1J 7 <br /> sEZ— griGN�3 ��t-7yr 2 <br /> 2 EACH personally <br /> and XIned the following docume I believe the information t the true,accuon rate as <br /> and compleproof of co t pliance FOR <br /> Photos Paperwork 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 a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: -R� /� S/ nl Title: <br /> A {�(, 0/iI Sp d ��1 �4�ti., <br /> Signature: Date: <br /> lf <br /> EHD 22-02-005 Rev 04/19112 <br />