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11 0 i <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sieov.org/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> An 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 /> En 4ronmental Health Department(EHD) address at the top of this form within 35 days of receipt of the <br /> Ins pection 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 days <br /> u ess 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 ($98). <br /> For this certification t0 be complete the operator of the site must include: <br /> • A statement documenting what corrective actions were taken orwill be taken for each violation <br /> • Copies of sample results/manifests/training records/other appropnat paperwork,�agd/or phot s <br /> tAoj <br /> verifying corrections �jjj �d iN ► ► ^ � y <br /> • Operator's certification � J � <br /> �p <br /> In pection Date: 45 g �U Inspected By <br /> FE cility Address:42, Z5 `v l EPA ID#: <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 informa ' to be true,Zacte, and complete: <br /> Photos Paperwork ement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. I 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: -ISAC/i l%*- le �"rti`d Title: ej"f� <br />