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kyung park 209 835 3731 p.2 <br /> SAN JOAQUIN COLNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E.Main St,Stockton,CA 95202-3029 <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web.w .sieov orglehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINR violations noted in the"Notice to Comply" in the attached Inspection Report must be <br /> corrected i 6thin 30 days of receipt of this inspection. This certification form must be submitted to the <br /> Enviromn tal Health Department (EHD)address at the top of this form within 35 days of receipt of the <br /> Inspection Report. <br /> All correct ons to other violations noted in the attached Inspection Report or Continuation Form; or <br /> disputes to any violations,are to be submitted using this certification and returned to EHD within 30 days <br /> unless otht rwise specified in the Inspection Report. <br /> Note: All KHD staff time associated with failing to comply by the above noted dates will be billed at <br /> the curren t hourly rate ($125). <br /> For thic certification to be complete the operator of the site must include: <br /> • A tement documenting what corrective actions were taken or will be taken for each violation <br /> • Co ies of sample results/manifests/training records/other appropriate paperwork,and/or photos <br /> vel g corrections <br /> • Op iator's certification <br /> Inspectio Date: Inspected By: rx/1 <br /> Facility A ddressilv I f�1!°� 1�J�EPA ID#CALQn2-0 <br /> I certif under penalty of law that: <br /> 1. I h 'e corrected the violations specified in the Inspection Report from the above-mentioned <br /> insl ection date. <br /> 2. I h2 'e personally examined the following documentation submitted as proof of compliance FOR <br /> EA H VIOLATION and I believe the information to be true, accurate,and complete: <br /> Photos _Paperwork _Statement <br /> 3. lan authorized to submit this certification on behalf of the Respondent. <br /> 4. I an aware that there are significant penalties for submitting false information,including the <br /> pos ibility of a fine and/or impnisortment fAr knno n violations. (HSC 25191) <br /> Name: Title: <br /> Signa e: Date: �� <br /> EHD 22-02-)05 Rev 08/10 <br />