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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.s*gov.org/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 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 certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. HSC 25185(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 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 JUL 18 20 <br /> Inspection Date: Inspected By: Ao`j Cgc c& 1 fi <br /> Facility Address: I51J5.3 K . ­i-hc)rn-W PA ID#: W� ()DO 2--f(.0 (A,09 <br /> wch j co 015 2 y Z <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 following docu, entation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the inf71D, <br /> n to be true, acc rate, and complete: <br /> Photos aperwork Statement fin_ �GZ <br /> WN 1�je.labe( cQ col',plq <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. 80� - Con mina w �Slc ..1' <br /> C-Ontai(1CK �� <br /> 4. 1 am aware that there are significant penalties for submitting false information, including tthheC_ to5-0- <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) - VY„\I-ea w aSk <br /> w,�l be c s��c�F1 <br /> � � win q yc«r <br /> Name:��e Q.��1 �(�`(���-1 Title: nCG(, e r of <br /> a cup w;�N <br /> Signatu �_)ft Date: -1 1 Z he sc -j +„ <br /> yAQ U F rc ts,,xr1 <br /> EHD 22-02-005 Rev 4/12 <br />