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6 0 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Te/e .�otw: (209) 468-3420 Fax: (209) 468-3433 Web:www.sociov.org/ehd <br /> RETURN TO COMPLMNCECERT CAMN <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. <br /> All corrections to other violations noted in the attached Inspection Report (IR) or Continuation f=orm, 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: M11 [EH-D =shaft time associated with failing to comply by the above noted dates viii he <br /> Willed at the current iraoudy rate. <br /> For this c tfica ion to 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 f <br /> verifying corrections <br /> * Operator's certification { <br /> Inspection Date: o4 i v z �� Inspected By; dz_ <br /> Facility Address: 1.-i2_s 4tvt-, ce,6_ ,3cuce EPA ID#: r_a>> cpl-tcs- : z <br /> CA <br /> I certify under penalty of law that: <br /> 1. 1 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 PaperworkStatement <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. jf-a, 0e akar, T Itle._ <br /> F <br /> Signature: �, � Date: <br /> i <br /> i <br /> I <br /> EHD 22-02-006 Rev 08,+08 <br /> I <br />