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SAN JOAQUIN COUNTY - <br /> ENVIRONMENTAL HEALTH DEPARTMENT - <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telep`on,:: (209) 468-3420 Fax:(2,0�9)468-3 3 Web:www.sioov.ord/ehd <br /> i <br /> RETURN TO COMPLIANCE ( ERTIFI ATION <br /> Any MINOR violations noted in the "Notice to Comply" in the attached InjsPection Report must be <br /> corrected within 30 days of receipt of this inspection. This certifi-cation"form 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-keport (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 /> • <br /> Operator's certification <br /> Inspection Date: 1 Inspected By: <br /> f <br /> Facility Address: �(? -7 �i • You EPA ID#: 0e-c oov G �) -)C f,� <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 complete: - <br /> Photos _*_Paperwork Statement II"cttar <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 /> l <br /> Name: 'T / d.? C.�/JC Z S c-: : <A1Title: <br /> Signature: r Date: t _ <br /> EHD 22-02-005 Rev 08/08 <br />