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SAN JOAQUIN COUNTY <br /> l ENviRQNMEN AL HEALTH DEPARTMENT <br /> f 600 East Main Street,Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Pax.(209)468-3433 Web:www.siQov.gTe/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 35 days of receipt of the <br /> Inspection Report. <br /> All go—awtions 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 ($98). <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 <br /> Inspection Date: -f _�. Inspected By: C:!2, e� 44,5;,�,A Y <br /> Facility Address: `3�� ..� ,y 1Zc� EPA ID#: 2 s7 33 <br /> I certify under penalty of lave that- <br /> . 1. <br /> hat:. 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, accurate, and complete: <br /> Photos_ '� Paperwork 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 known violations. (HSC 25191) <br /> Name: i Title: ,r <br /> Signature: Date: <br /> ITur-% 1�n All nnr n .. 1 Y /^17 <br /> 111 80108S860Z I •0N Xd� 'HM SS31 KO 0004 KV 6� :60 IH/800Z/51/EH <br />