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1 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3`d Floor,Stockton, CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sj og v.or <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 /> 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 (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 /> For this certification t0 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: 9?' C -0 L Inspected By: /nS •OLA v f, t (5--d <br /> Facility Address: -7-7 EPA ID#: CA <br /> -E-o e-U_4-ems C pt <br /> I certify under penalty of law that: o, S'2-� 7-- <br /> 1. I have corrected the violation specified in he Inspection Report from the above-mentioned , <br /> inspection date. cLw4we--o 't," <br /> following do entation submitted as proof of compliance FOR <br /> 2. 1 have pers ally examine <br /> EACH VIOLAT and believe t4e information to b true, accurate, and {om 1 te: <br /> Photos Paperwork Statement <br /> -�- <br /> 3. I am authorized to submit this certification behalf of Respondent. <br /> ✓ e-a.wt- <br /> 4. I am aware that there are significant penalties for submitting false information, including the <br /> possibilit�y�of as fie anaimpri nment for �own v' lations. (HSC 2511) <br /> Ve,, <br /> Name: ' LG Title: <br /> Signature: Date: 2'. 6 <br /> l �-o rnS. i�_e ,, <br /> EHD 22-02-005 Rev 12-04 �'�' —'�' gf�t dG 6 <br />