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�: <br /> i ' _ <br /> SAN JOAQUI N COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT - -' <br /> 600 East Main Sheet,Stockton,CA 95202-3029 l r , }`•'� <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www sieov.ora/`1rd <br /> JAN 12 1 <br /> RETURN TO COMPLIANCE CERTIFICATION 9BNJ0.W UI,JCOUNfY <br /> ENV!-0Nh°�-idTAL <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report h5MV DEPARTMENT <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 /> Inspection 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 /> 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($122). <br /> For this certification to be complete 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,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date:h It I to Inspected By: Z rg,4 <br /> Facility Address: 1 f?o{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 information to be true,accurate,and complete: <br /> Photos PaperworkStatement <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 information,including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: If �i'r �� Title: P/la&W S &Ltw <br /> Signature: Date: ('/17 <br /> f j <br /> EHD 22-02-005 Rev 08/10 <br />