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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3'd Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www,§igov.ore%hd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MIN'OR'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 corrections to other violations noted in the attached Inspection Report(1R)or Continuation Form,or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 60 days <br /> unless otherwise specified in the 1R <br /> EOr 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 bate: 7-2 Inspected By:C-.-A;W I NN,y. <br /> _ Facility Address:� �3 � �Yl>� y (�c 0 EPA ID#: <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I 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 2519 1) <br /> Name: ,1b��" rb ,g- Title: �t�- <br /> Signature: ro, Date: - -T4 <br /> EHD 22-02-005 Rev 12-04 <br /> Z00 'd 901099960Z i 'ON M 'HM SSH'I HO.d QON Yid 91 :01 NONA00Z/90/did <br />