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U <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton, CA 95202-3029 <br /> Telephone:(209)4683420 Fax:(209)488-3433 Web.www,>s&ay.ofCJtV-d <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any Mi R violations noted in the"Notice to Comply' in the attached Inspection Report must be <br /> corm w ;n 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 25404.1.20)() or Continuation Form,or <br /> All coy chops o othe vol s noted in the attached Inspection Report(IR) <br /> disputes o any v o a ions, are to be submitted using this certification and returned to EHD within d days <br /> unless otherwise specified in the Inspection Report. HSC 251 g5(c)(3) <br /> Note: All EWD staff time associated with failing to Comply by the above noted dates will be <br /> billed at the current hourl rata. Of the site must include: <br /> For this certification to be com yet,ere eojc will be taken far each violation <br /> . A Statement documentingg what Corrective a records/other appropriate paperwork. and/or Photos <br /> . Copies of sample resultslman►fests/trarnrng <br /> verifying corrections <br /> . O eratoes certification <br /> '��1-- Inspected By: 1v'1 � tv A�.iJca <br /> Inspection Date:_ <br /> -� <br /> Facility Address: � EPA ID#: <br /> 'r <br /> I certify under penalty of law that. <br /> 1. ! have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined the foikmting <br /> 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, t am authorized to submit this certification on behalf of the Respondent. <br /> 4, 1 am aware that there are significant penalties or vbmitti�s�tHS2information, including the <br /> possibility of a fine and/or imprisonment for <br /> Tibe:_ <br /> Name: <br /> Date° Z —Z-�—/ 2-- <br /> Signature: <br /> EHD 2Zo2-005 flew 49M I <br />