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SAN.JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East -Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 4683420. Fax: (201x) 46'8=3433 Web: .s' ov.or / Md <br />RETURN TO' COMPLIANCECERTIFICATION <br />Any MINOR violations noted in the ".Notice to Comply" in the attached Inspection} Report'must 6e <br />corrected within 30 dam of receipt of this inspection. This certification form must. be s,ubrnitted to the <br />Environental Health Department (EF(D) address at the top of..this form within 30 days of receipt of the <br />m <br />Inspection Report. <br />All c2rrect'ons Lo other violations noted in the attached Inspection Report (IR) or Continuation f=orm,: or <br />disputes to any violations, are to be says <br />ubmitted using this certification and returned to EHD <br />disputes <br />d <br />unless otherwisespecifiedin the In"ction Report, _ <br />Note: All EHD staff time associated with falling to comply by the above noted dateis will be <br />billed at the current hourly rate. <br />For this certification. t0 Ike Complete the operator of the.sito:muet include: <br />. A statement documenting what corrective actions were taken or will be taken for each violation <br />• Copies of sample.resultslmanffests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />. Opsrator's cert cation <br />Inspection Date: �r�� <br />Inspected'fly: C•' <br />.a <br />Facility Address: EP&[D#:, <br />certify under penalty of law that: <br />1. - <br />,I-have -corrected the violatiosp$cified in the Inspectior�Report.from the above-mentioned <br />r►s <br />inspection date. <br />2. 1 have personally examined the.following documentation submitted as.proof of oompGehee 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 />Title; l CQ �' L�j <br />Name: <br />I Date: <br />Signature. - <br />EHD 22-02-005 Rev 10100 <br />ZO'd 9V:Sl OIOZ cZ Inr O16199b60Z:X6J ]Qd 10 NVA <br />