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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.§;jciov,o /ehd <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 ins "on. This certification form must be submitted to the <br /> Environmental Health Department(EHD)addressat the tip 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 codification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD staff time associated with 411ing to comply by the above noted dates Will be <br /> billed at the current hourly rate. <br /> For this certification to becomplee the operator of the site must include: <br /> e A statement documenting what corrective aciie' ns were taken or will be taken for each violation <br /> 9 Copies of sample results/manifestsitraining.rgpoMo/ <br /> other appropriate paperwork, and/or photos <br /> verifying corrections <br /> a Operator's certification <br /> Inspection Date: InspectedBy: <br /> 7 <br /> Facility Address: EPA ID#: 9Z �k Zff 2,- <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 followipR qpc4rnentation submitted as proof of compliance FOR <br /> EACH VIOLATION,and I believe the inforni' <br /> qjjqp to be true, accurate, and complete: <br /> Photos e P�p rwork Statement <br /> 3. 1 am authorized to submit this 9 <br /> certificatiP ri 9 be Respondent <br /> ,half of the <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonmeriffO knoWn violations. (HSC 25191) <br /> Name: T§r-E'V E 1<0CIA&776E Title: 1&,ftarele <br /> Signature:<,, Date: <br /> EHD 22-02-005 Rev 10109 <br />