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Mail to: P.O. Box 1107, Stockton, qA 95201-1107 (209) 465-3421 • Stockton (559) 233-7261 • Fresno <br />Administration: (209) 944-9115 • F� 109) 466-1910 (209) 667-0236 -' ock (559) 698-7201 • Tranquility <br />P <br />I �7,, I u`' <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />(209) 468-3420 Fax: (209) 468-3433 Web: www.$ oy.ora/ehd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MiN violations noted �n the "Notice to Comply" in the attached Inspection Report must be <br />corrected within 30 days of ceipt of this inspection. This certification form must be submitted to the <br />Environmental Health Depa snt (EHD) address at the top of this form within 30 days of receipt of the <br />Inspection Report. HSC 254 4.1.2(c)(1) <br />All corrections to o he sol .i ns noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to any violations, aro to be submitted using this certification and returned to EHD wsths_n 30 days <br />unless otherwise specified in the Inspection Report. HSC 25185(c)(3) <br />Note: All EHD staff timessociated with falling to comply by the above noted dates will be <br />bill �d at the curre , t hourly rate. <br />For this certificatl n to be Complete the operator of the site must include: <br />• A statement documents g what corrective actions were taken or will be taken for each violation <br />• Copies of sample result/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: f p Inspected By: Stacy Rivera <br />Facility Address: V W, 6 fim% EPA ID#: <br />-tf-.c Gfi 9S3 fa <br />I certify under penalty o law that: GA L ow / ,& 3e <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. 1 have personally eX mined 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 <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 fineend/or imprisonment for known violations. (HSC 25191) <br />Name: v 7,rv-4—^ Title: L, s4 <br />Sianature' / 9 M Date: % ��/ <br />