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002454 <br /> SAN JOAQUIN COUNTY <br /> ENARQNMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telep::one:(209)468-3420 Fax:(209)40.3433 Web:wwwsigov.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 /> I <br /> All corrections to other violations noted in the attached Inspection Report(IR)or Continuation Form, or <br /> disputes to any violatians, ere to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. <br /> tote: All EHD staff-time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> f <br /> For this certification t0 be corrI lett: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, andlor photos <br /> verifying corrections <br /> Creratol certification D <br /> Inspection Date: It I `fid I I I Inspected By: C`I�h i✓Lra <br /> Facility Address: �J SS S•S ' flwi�, %C140"l ID#: �L. O 00 '3 ) S ' 0� <br /> I certify under penalty of law that: <br /> 1. 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 /> i <br /> 1/- Photos ✓ Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> i <br /> 4 lam aware that there are significant penalties for submitting false information, Including the <br /> possibility of a fine andlor imprisonment for known violations, (HSC 2�5,11t91) <br /> Name: Q ^ Title: <br /> Signature: 0-3 Date dl — O a- c1O iyrya yay <br /> CV L <br /> as <br /> EHe 22-01-005 Rer oAIAA JAN ON 2012 <br /> S -d JOAu1;A COUNT,' <br /> ENIARONMENTAL <br /> ` HEALTH DEPARTMENT <br />