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LM 7 >� • SAN JOAQUIN COUNTY I • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> f1 304 East Weber Awniue,3'6 Floor,Stockton,CA 95202-2708 <br /> Telephone.(209)468-3420 Fax:(209)468-3433 Web: w. oov.or,,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 a the <br /> inspection <br /> rep 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 be submitted using this certification and returned to.E <br /> unless otherwise specified in the IR. ?within 60 days <br /> For this certification t0 b; COMPIetC the operator of the site must includ : <br /> • A statement documenting what corrective actions were taken or will be taken for ach violation <br /> • Copies of sample results/manitests/training records/other <br /> verifying correappropriate paperwork, and/or photos <br /> ctions <br /> • Operator's certification <br /> I, <br /> Inspection Date: a Inspected By: L(/ Lt . <br /> Facility Address: 7✓ EPA : <br /> I certify under penalty of law that: <br /> I. 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 /> Fhotos 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 2In <br /> 5191) <br /> Name: r4 ✓ - Title: r} f?T nl2JL <br /> Sigmmture: fc _ ttic t)Mkm✓3 Date: 3 <br /> EHD 22-02-005 Rev 12-04 <br /> 1/1:d ££b£89b:01 2US£2£8602 dI8Ndd:W0ad 22:10 9002-b1-dUW <br />