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2012-08-20 16:03 >> 2094683433 P 1/7 <br /> SAN JOAQUIN COUNTY f� T <br /> ENVIRONMENTAL HEALTH DEPARTMENT i� ? `( q " 4 <br /> 1868 East Hazelton Avenue, Stockton, California 95205-5232 `= .1 !. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov_orglehd <br /> AUG 2 0 <br /> RETURN TO COMPLIANCE CERTIFICATION "` Ty <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. HSC 25404.1.2(c)(1) <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. HSC 25185(c)(3) <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. <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: 2 �' �� -- Inspected By: 1 t <br /> Facility Address: C EPA ID#: Lr� <br /> 1 certify under penalty of law that: <br /> 1. 1 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. I 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 <br /> of a fine and/or imprisonment for <br /> known violations. (HSC 25191) <br /> Name: w f �1 � Title., L� 61 CrZi <br /> Signature Date- U17,6 Z CS I Z <br /> EHE)22-02-005 Rev 04/19/12 <br />