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JUN 20 2005 14 : 22 FR SAFEWAY LOSS CONTROL25 746 8142 TO 912094683433 P . 01i01 <br /> 1 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,P Floor,Stockton,CA 95202-2708 <br /> Telephnee:(209)468-3420 Fax:(209)468-3433 Web:www sjgoy.ore/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 corrections to other violations noted in the attached Inspection Report(3R)or Continuation Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 60 dam <br /> unless otherwise specified in the.]R- <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: q l lei 6b Inspected By: &4 vja le9 v-�, <br /> Facility Address: L,q2 S &�;i C.,&( ,SkGWEPA ID#: CAL QCbaBD76 g <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. 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 /> PhotosPaperwork Statement <br /> 3. 1 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: Title: f lSl moi MeL�2, <br /> Signature: Date: C-� :�v o$ <br /> EHD 22-02-005 Rev 12-04 <br /> ** TOTAL PA6E . 01 ** <br />