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• SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTR DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web.www.sigov.org/e <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(IR)or Continuation Form, or <br /> disputes to any violations,are to submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All E1ID staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate($122). <br /> FOT tI11S CO2 t1f1CSt10I1 t0 be COTI1�10te 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 /> venfying corrections <br /> • Operator's certification r <br /> Inspection Date: (y/Z-?/// Inspected By: 6C <br /> Facility Address:,'2�DW7_0A*.-r0Q EPA ID#: GIs}"1-30my <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. I 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 /> 1photos— /� 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 2,t5,,1.9+^11) <br /> Name: t Oft Age <br /> Title: 6w , <br /> Signature: Date: <br /> EHD 22-02-005 Rev10 <br />