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10/24"00Y 18:38 FAX <br /> 005/005 <br /> `. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT ` <br /> 600 East Main StreK Stockton,CA 86202-3029 ` <br /> Telephone:(209)468.3420 Fax:(209)468-3433 Web:mvw sioov.orc/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. <br /> All gplfections to other violations noted In the attached Inspection Report(IR) or Continuation Forth, or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD mdthjn-92 days <br /> unless otherwise specified in the Inspection Report. <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 resuits/manifests/treining records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: 4�7- 2/-20/0 Inspected By: L?a—r- 17eg" <br /> Facility Address: r;Oo F Via; ' EPA ID#: CdGcec 26t 2g <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 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. (NSC 26191) <br /> Name: �� s f <�, 7- Ei« _ Title: <br /> 1 <br /> Si nature: Date: -13-20/o <br /> END 12-02-000 Rw IWO <br />