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RECEIVED <br /> ►JUS v <br /> :.:., <br /> SAN JOAQUIN COUNTY <br /> HF1aLTH ENvixONMENTAL HEALTH DEPARTMENT <br /> O <br /> ENVIRONMENTAL <br /> 29 <br /> PERMITISERVICES 600 East Main Street,Stockton, A <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.si�ov.org/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspecdon Report must be <br /> corrected within 30 days 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 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 billed at <br /> the current hourly rate($122). <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 <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: ��, 1 { f Inspected By: Stacy Rivera <br /> Facility Address: k' EPA ID#: <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. 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true,acurate,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 kno violations. (HSC 25191) <br /> Name:4Rev <br /> �� Title: o t9,1 �,Q� <br /> SignatEHD 22-02 <br />