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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3rd Floor,Stockton, CA 95202-2708 <br /> Telephone(209)468-3420 Far:(209)468-3433 Web.www.si¢ov.org/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 /> En ' ental Health De <br /> report. partment(EHD) address at the top of this form within 35 days of receipt of they, w <br /> " <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 60 days <br /> unless otherwise specified in the IR. <br /> « 6a <br /> For this certification to 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: 12/5 I Gtn Inspected By: 211!,j 'VC-V-) 'R vie <br /> 1-1 <br /> Facility Address:_ j 03_1 w ,-r-F- /Nvt EPA ID#: lA L_000:3140 -7 5 <br /> nn�r�Tltc��, caa �153j� <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 V 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: M�.-1 � l 11/1Title: LAArylil'115'IV;-4-}'Oi— <br /> Signature: A _ I vu sl Date: i 5J1 ICU <br /> EHD 22-02-005 Rev 12-04 <br />