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} i <br /> SAN JOAQUIN COUNTY <br /> ENv(RONMENTAL HEALTH DEPARTMENT <br /> 640 East Main Street,Stockton,CA 95202-3029 <br /> - - - �'el�phone�(�09)-468-342x-F�'a�-(.2,D�1}1i68-343 -N!eb;�sia��glchd _. <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the 54Notice to Comply"in the attached Inspection Report must be <br /> corrected within 30 days of receipt of this inspection. This certification fornl must be submitted to the <br /> Enviro=ental Health Department (EHD) address at the top of this form within 35 days of receipt of the <br /> Jnspection 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 be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All ERD staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate ($98). <br /> For this certification t0 be cOZI plete the operator of the site roust 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-, .-3�f c� Inspected By: ��' V,� F1'1I� <br /> Facility Address: 7 S A2]ge EPA ID#: �/ <br /> I certify under penalty of law that: <br /> 1. I have coxTected 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 /> 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 25191) <br /> Name:�-s� f��%� ,% Title: Xgw-t/ -�g, az <br /> i , <br /> Signature: f Date: <br /> 000 'd 90i0998E0Zi 'ON Y,bd 'HM SS31 U 900, PSS' 90 :90 HL/9002/N/qnf <br />