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SAN JOAQUIN COUNTY <br /> QkviRoNmENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.orgL <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 da vs of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department(EHD)address at the top of this form within 35 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 davs <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 billed at <br /> the current hourly rate($122). <br /> For this certification t0 be complete the operator of the site must include: <br /> • A statement documenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> .�� <br /> Inspection Date: 6_d�� Inspected By:""'/C��Z <br /> Facility Address: .Z00S A(ahv RS -rR¢cY cn EPA ID#: eA 0 9 7�5�$ <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION andI be li ve the information to be true, accurate, and complete: <br /> Photos�aperwork _Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. I 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: ,L L►A S A v i 1 41 Title: A L- Aju S A►2 h-14 Y AiAvl;�w vCC <br /> S v VQ 2v1sok <br /> Signature: Date: —/ --GD/# <br /> EHD 22-02-005 Rev /_l <br /> 0 <br />