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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN, <br /> 600 East Main Street, Stockton, CA 95202-3029 'F <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www seaov oralehd , <br /> SEP 2 g 2nnq <br /> RETURN TO COMPLIANCE CERTIFICATL `Q"NTY <br /> EtT <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 30 days of receipt of the <br /> Inspection Report. <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 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 <br /> billed at the current hourly rate ($105). <br /> For this certification t0 be comptetetheoperator ofthe 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:_ /Z-3� Inspected By: jef&nl W o �. 5 <br /> Facility Address:_ iz,7c, SI0.,,, Qt, EPA ID#: C6.( 06o 2A0 la <br /> S +Oc fA40- cw qd.a- IS- <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 /> Photos _Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 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 /> y� <br /> Name: f & O✓sref Title:—Ad +a!a!'.G✓ <br /> Signature: Date: y 2S�d <br /> PHa 22-02-M Rev 08108 <br /> ['d 6EI,6LE660Z S3211]Ol O�Eb'd OZZ LL 60 8Z deS <br />