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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E.Maul St.,Stockton,CA 95202-3029 <br /> Telephone.(209)468-3420 Farx:(209)468-3433 Web.www•siQoy omJehd <br /> RETURN TO CONIPLYANCE CERTMCATION <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 or Continuation Form,or <br /> disputes to any violations,are to be submitted using this certification and returned to EHD within 30 dans <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EBD staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate(5115). <br /> For this certification t0 be COMPIete 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/mani£ests/training records/other appropriate paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: S /& Ap Inspected By: liGlce/��e h`ex r <br /> Y <br /> Facility Address: G5-y-'2 1kNEPA ID#: CSG &-).00 91Z091 <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_xstatement <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 2519 1) <br /> Name: i � yG�y Title: <br /> z <br /> Signature: Date: <br /> EHD 22-02-005 Re 10-07 <br />