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SAN JOAQUIN COUNTY �y t <br />ENVIPONMENTAL HEALTH DEPARTMENT U1. <br />boo East Main Street, Stockton, CA 96202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www. 19 V.o� rgle_hd L 0 2049 <br />8A/V . r,, . __ <br />NFq�r}�Cic�9�i'V. q� ry <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 Iform 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 />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 <br />billed at the current hourly rate. <br />For this certification t0 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 />certification <br />Inspection Date; <br />Inspected By: <br />� ' ' •� • :� ' iR .cam i .� • ✓ � '� — <br />I certify under penalty of law that: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. 1 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 completer <br />Photos L,". -Paperwork Statement <br />3. 1 am authorized to submit this certification on behalf of the Respondent. <br />4. 1 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:U f ✓� �, , <br />nature: <br />Date: <br />