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1212812009 10: 37 20985850cG ... GUTS FO.D F�L PAGE 01108 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)4683433 Web;www. acg4,ar_g{ehd V; <br /> RETURN TO COMPLIANCE CERTI>=IC,ATAL 2 S 2909 <br /> SAN JOA UN C& NPI <br /> Any MINOR violations noted In the"Notice to Comply" in the attached Inspection R Mit-;T <br /> corrected within 30 days of receipt of this inspection. This certification form must be su m4& tone <br /> Environmental 'Health Department (FHD) address at the top of this form within 30 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 30.day5 <br /> unless otherwise specified in the Inspection Report. <br /> (Vote: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current Dourly rate. <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 /> • Copies of sample results/manifests/training recordslother appropriate paperwork, and/or photos <br /> verifying corrections <br /> Operator's certification <br /> Inspection Date: a�" d Inspected By: <br /> Facility Address: ILL S _Fh 00,EPA ID#: <br /> I certify under penalty of law that: <br /> T. I 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. (HSC 25191) <br /> Name: , i - -- Title: � vJ!i/;4P_ <br /> 1ZSignature: Date: fU <br /> EHO 22.02.W5 Rnu ORMS <br />