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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www_sloov.orp/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 Department(EHD)address at the top of this form within 30 days of receipt of the <br /> Inspection Report. HSC 25404.1.2(c)(1) <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 certlflcatlon and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. HSC 25185(c)(3) <br /> I <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this Certification t0 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 <br /> verifying corrections <br /> Operator's certification <br /> Inspection Date: V' 1 142 Inspected By:StaCy Rivera <br /> Facility Address: 48175c <Sf(y xjgq EPA ID#: <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-lil�ntlone <br /> inspection date. 424, Ca <br /> 2. 1 have personally examined the following documentation submitted as pro ms n iiOR <br /> EACH VIOLATION and I believe the information to be true, accurate, and co0% <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: J/ '•� Title: mlxllllf�er <br /> 41 <br /> Signature: A/Vk Date: 1214 2C - <br /> EHD 22-0z-=Ray 09111 <br /> 400/L00 @ XHd LL 9L 900Z/SZ/00 <br />