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rwc-an-caav w•co rrum. 1W Iuw�r.w <br /> SAN.TOAQUIN COUNTY <br /> F-Nv(R ONMENTAL TIEALTR 1)L,t'A1k1M3NT <br /> 1868 E.Rvettan Avu.,Stockton,CA 95205-6232 <br /> I"elephome.(209)468-3420 Pair:0209)468-3433 Wpb: <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> A.ny MINOF 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 35 days of receipt of the <br /> Lispection Report. <br /> All corrections to other violatious noted in the attached Inspection Report or Coutiauation corm,or <br /> disputes to any violations,are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All JKT-ED staff thue associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate(3125). <br /> For this certification t0 be COMPICtetheOpctatorofthe site mustincludo: <br /> • A statement documenting what corrective actions were taken Or will betaken for each violation <br /> • ('.npies of sample results/rnani fects/training records/other appropriate papoLwork, and/or photos <br /> verifying Corrections <br /> • Operator's cQr(Ifll:ation <br /> Inspection Date: -3 3 fmipccled By: <br /> �,Hy T,r <br /> Facility Address: 573 E, PCscac oVe, EPAITX6: CA Lociop3 *2(� <br /> I ccrtit'y under penalty of law that: <br /> I. T have cormetod the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2 I have personally examined the following dncumeatatiou Submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to bo nuc, accurate,and eompictc: <br /> Photos Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. I am aware that there are significant penalties for submitting false ioformatiun,inchuling the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: 142,1A r ev �e Title: r - I&V:V"• Mc jSe ✓:�� <br /> Signature: _ Dale: <br />