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U4/ ::11_':JUO U ZO'74ndJ4,5J Y'lrIN rLUUK ri-iut _a SAA JOAQUYN COUNTY P-NVIRONMENTAL HEALTH DEPARTMENT 304 East Weber:kvenut,3`4 Floor,Stockton,CA 95202-2708 Telephone:(209)468-3430 Fax:(209)468-3433 Web:_r.+rww.sjgov.orElehd RETURN TO COMPLIANCE CERTIFICATION Ana'MINOR violations noted in the"Notice to Comply"in the attachedinspection report roust be corrected within 30 days of receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD) address at the top of this form within 35 days of receipt of the inspection repo: . All corrections to other violations noted in the attached Snspeetion Report(IR) or Continuation Form, or disputes to any violations, are to be submitted using this certification,and returned to EHD within 60 dans unless otherwise specified in the IR. For this certification t0 be COlnplete the operator of the site must include: + A statement documenting what corrective actions were taken or will be taken for each violation • Copies of sample results/manifests/training recards/other appropriate paperwork, and/or photos verifying corrections • Operator's certification. Inspection Date: 6(1'' Inspected By: M�c►,t �,, L� i Facility Address: c2h EPA IDS; I certify under penalty of law that: i. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. 2. I have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and I believe the i_nfbrniation to be true, accurate, and complete: ✓ Photos _ Pepervozk ✓acStatement 3. I am authorized to submit this certification on behalf of the Respondent. 4. I am aware That there are siEmificant penalties for Submitting false information, including the possibility of a fine andfor imprisonment for known violations. (HSC 25191) Name: +� < eXQ _—) N -- % -Title: Cnnp/,G�u ,o�I< -- Signature, Date: Iq EHD 22-02-005 Rev 12-0s