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SAN JOAQUIN COUNTV <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Alain Street,Stockton,CA 95202-3029 <br /> Telephone: (209)468-2420 Fax: (209)465-3433 i'Veh tix�x<«.sic o,.oralehd <br /> RETURN TO COMPLIANCE CERTIF1C ATION <br /> .Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 dam 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 /> inspection Deport. <br /> All corrections to otlser violations noted in the attached Inspection Report (IR) or Continuation Forrn, 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 EHD staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate (S98). <br /> For this certification t0 be COTm plete the operator of the site must include: <br /> a A statement documenting what corrective actions were taken or will be taken for each violation <br /> A Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> s Operator's certification <br /> Inspection Date:— r _ Inspected Dy: a c�L��t� <br /> I~acility Address: EPA ID#: Q_0 Q._-1 �—- <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified ill the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined the following documentation submitter) as proof of compliance FOR <br /> EACH VIOLATION and I believe the inforination to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3. 1 am authori.zed to submit this certification on behalf of the Respondent. <br /> 4. 1 aur aware that there are significant penalties for submitting false inforination, including the <br /> possibility of a fine and/or imprisoranent for la-iown violations. (I-ISC 25191) <br /> Name: Titic:_��� �Q Y�M,a,9.----- <br /> . � <br /> Signature: r Date: 7, l <br />