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0 SAN JOAQUIN COUNTY <br />ENVI RONMENTAL RVALT14 DEPARTMENT <br />304 East Weber Avenue, 3'6 Floor, Stockton, CA 452022708 <br />Telephone: (249) 468-3420 Farr: (209) 468-3433 Web: ww w.s' oT#!y,org(ehd <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 Depanment (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 be submitted using this certification and returned to EHD within 60 days <br />unless otherwise specified in the IR_ <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 be taken for each violation <br />o Copies of sample results/rnanifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: Inspected By: _ <br />Facili address: �z 5,- t: EPA 11)#%,_-_ <br />I certify under penalty of law that: <br />1. 1 have corrected the violatiozis 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. 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:�;c Title: <br />Signature:.. . °` .. �, ; §; T �.. - - Dater <br />EHD jq_ ,'d? -016 [� Z - o'�-04 8VH-£t6-6H ' dSNddi dIM WdL l Z 90H 'G 'AEA <br />