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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 Fac.(209)468-3433 Web:w wjgov.org/chd <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 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to other violations noted in the attached Inspection Report(1R) 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 EHD staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate($122). <br /> For this certification to be complete.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,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: 5 - 17 " Z ri Inspected By: T-k!j !A4V <br /> Facility Address:z57J /vTIt 4 p II-WEPA ID#: eRt t�oo'i! LW -I- <br /> I <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. I have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and II believe the information to be true,accurate, and complete: <br /> V Photos Paperwork Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. I 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 2519 1) <br /> Name: tyml M,riT w% Title: 5 RFCT �ALi TRTld'V MAAJAr FL <br /> Signature: Date: 5/1,51 7.0 \ <br /> EHD 22-02-005 Rev 08/10 <br />