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San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Airy MINOR ViOiatiGns noted in Lne`Notice to Comply"iii he attache-1 inspection Report must be corrected within 30 days OT <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address <br /> the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other violations noted in the attached inspection Report(IR)or Continuation Form, or disputes to any <br /> violations, are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the <br /> Inspection Report. HSC 25185(c)(3) <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 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 verifying corrections <br /> Inspection Bate: _ _ Inspected By: STACY RIVER, <br /> Facility Address: 5 __ _ __ EPA ID: <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> 1 believe the information to be true, accurate, and complete: <br /> Photos PaperworkY 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 possibility of a fine and/ <br /> imprisonment for known violations. (HSC 25191) <br /> Name: rg Y ' Y' Title: boa <br /> Signature: Date: S J � <br /> C&Rs <br /> to I - We 5v�+ -T-D <br /> B o3 - � �I� • A <br /> got .. W1,11 <br /> lbs-tt..� ��.r�� a�iti:� vr� �r►�!� �-�.c�° �� c��g -�` b.c,�,� <br /> l <br />