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• SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3'd Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Weh:www.sjggv.org/ehd <br /> RETURN•,TO COMPLIANCE CERTIFICATION <br /> RTIFICATION <br /> �,i. S tl.�.�3... ,• ,.�-. lk�'I�•i, �•':}ti . 1,ti' r,i, i :?il I .. i <br /> An MINOR violations noted m the Notic d inspection reppr must <br /> Any e to Comply"in the attached p p be <br /> corrected within 30 days of receipt of this inspection ,This certificatioi l form must be submitted to the <br /> Environmental Health Departruent(EHD)address at the top of this form within 35 days of receipt of the f <br /> inspection report. ,_. <br /> All coi*ctions to other violations noted in the attached Inspection Deport(IR) or Continuation Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 60 days <br /> unless otherwise specified in the IR. <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 records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: l +� 0 Inspected By: 17U4 <br /> Facility Address-5757 . ' 'iF/c. EPA ID#:CAL 0CW b��'L <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. I 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: �� ,► Title: <br /> i titreDate: I ~ <br /> S gnat : <br /> ,R <br /> EHD 22-02-005 Rev 12-04 <br /> 1 'd 1E96-BL , (602) LLZtr# 4Jew-A d6E :Z1 LO 11 ueC <br />