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MAY ?y 101 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Mein <br /> Telephone:(209Street, <br /> )88 420 Fax.(209)468- »3 <br /> 34 3 Web2www.slaov,oralehd NF11' DEFT <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 Inspection. This certification form must be submitted to the <br /> Environmental Health Department(EHD)address at the top of this form within 30 days of receipt of the <br /> 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 <br /> disputes to any violations,are to be submitted using this certlflcation and returned to EHD within 30 days, <br /> unless otherwise specified In the Inspection Report. HSC 26186(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 <br /> verifying corrections <br /> . Operator's certification <br /> Inspection Date: 5/a/I Inspected By:Stacy Rivera <br /> Facility Address:&& rcZ Apar EPA ID#: <br /> 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 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-X—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 fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: Title;SM. <br /> $I nature: Date: <br /> SHO 12-02-005 Rev 00111 <br /> Z �8Z9 X85 St�Z VJ 'uo}�:)o;s sdsn wv ov cl <br />