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JJ �' <br /> SAN JOAQUIN COUNTY jr 5 ZQ�z <br /> ENVIRONMENTAL HEALTH DEPAR-WENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web.www.si40v.0rg1ehd' '0~±Uto,ro0l-4.1 <br /> i"-:,,01'iuENTAL. <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 to be complete the operator of the site must include: <br /> • A statement documenting what corrective actions were taken orwill be taken for each violation <br /> • Copies of sample results/manifests/training records/other appropriate paperwork,and/or photos <br /> verifying corrections <br /> • Operators certification <br /> Inspection Date: ? Inspected By:Stacy Rivera <br /> Facility Address: �),� S, EL hpMyb � EPA lD#: <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 /> r' 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 _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:_ X411 l tt, q h Title: tjj4. U97 IrXLt 0(- <br /> Signature: C* Date: fpr C- o Z <br /> awo 22-02-005 Rev 09111 <br /> l'd Z160Z8660Z zapieneiva6n3 dEI:ZOZlgo 1nf <br />