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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT. <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www_siaov.org/ehd <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 30 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 />i his certification and returned to EHD within 30 days <br />disputes to any violations, are to be submitted us <br />unless otherwise Ispeclfied in the Inspection Report. <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 docdmenting 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: <br />Facility Address: <br />I certify under penalty of law that: <br />Inspected By: <br />EPA ID#:_1�5 O�aO <br />1. i 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. 1 am authorized to submit this certification on behalf of the Respondent. <br />4. lam 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 />Name: <br />Signature: <br />EHD 22.02-005 Rev 10109 <br />Date: <br />to/te 39td DNI SIO 3ddOHl WIT T58T-89c-607_-T 60:bT eTeZ,80,/Z0 <br />