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Apr 28 09 05:16p p.2 <br /> .002454 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600.East Main Street, Stockton, CA 95202-3029 <br /> Telep:`one:(209) 46B-3420 Fax:(209)468-3433 Web:www.si4cv.orgJehd <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. <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 tailing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> i <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 /> • <br /> operator's certification <br /> Inspection Date: inspected By: <br /> Facility Address: �1c�u� ��c - EPA ID#: <br /> 1 certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> i <br /> inspection date. I <br /> 2. l have personally examined the roiluwing docunientation submitted as proof of cornpliann.P FOR <br /> EACH VIOLATION anal I believe the-inform 3tion•to be true, accurate, and complete: <br /> Photos Paperwork N Statement i <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4 1 am aware that there are signiticant penanles rcr suUcrliuiI ly rcilsG information, inotuding the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name, Title: L�L�� N - <br /> ` i <br /> Signature: Date- �Vz ' to <br /> EHD 22-02405 Rev 08o0e <br />