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Wicntilch20 <br />SAN JOAQUIN CUUNTY `r �,A;Z2-_ - Z Ll Cc <br />le- <br />RNv1R0NMENTAL HrALTY1 DEPARTMENT 'Fal t d ID P` PIX 10-b64 <br />600 East Main Sheet, Stockton, CA 95202-3029 Ce" {-aLN(/rS 0 R[A-k <br />Telephone: (209) 468-3420 Fina: (209) 468-3433 Web: www.sjggv.or. chd }r <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 dates of receipt of this inspection. This certification form must be submitted to the <br />Environmental Health Department (F. HD) 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 Elf within 60 days <br />unless otherwise specified in the IR. -i. <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/othcr appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />inspection Date.:_ B -zvo � _ Inspected By: UV11l,�1 Nq i__ <br />Facility Address: /S,;!,i yVLJid 1//fW EI'A IDI#: _OAVe)0 0 70 qa _w <br />I 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. [ have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and l believe the information to be true, accurate, and complete: <br />Photos PaperworkStatement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. T am aware that there are significant penalties for submitting false information, including the <br />possibility of a fine and/or imprisonment for known violations. (IISC 2519 1) <br />Namc: &V t yr Pa Title: L iryaS�G T{,6 <br />Signature: Date: <br />F.HI) 9.9-09.-005 Rev 05/07 <br />2Td WH20 : L O LOOE OZ -unf V9V0Z9VG0Z : 'ON XHd H I N�]Od I -11J0 d0 1-10H : WOEU <br />