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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Teleph ne: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.orWehd <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 Depa ment (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 30 days <br />unless otherwise specified in the Inspection Report. <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at <br />the current hourly rate ($9 ). <br />For this Cer tif1Catio� t0 be Complete the operator of the site must include: <br />• A statement docume ' ting what corrective actions were taken or will be taken for each violation <br />• Copies of sample res Its/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certificati n <br />Inspection Date: Inspected By: -A,,7e H so-gm%IL <br />Facility Address: <br />I certify under penalty of1law that: <br />1. I have corrected the olations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. I have personally exam fined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION �nd I believe the information to be true, accurate, and complete: <br />Photos 5{ Paperwork X_Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. I am aware that there �re significant penalties for submitting false information, including the <br />possibility of a fine ar�d/or imprisonment for known violations. (HSC 25191) <br />Name: <br />Si <br />EHD 22-02-005 Rev 11/07 <br />Title: H p2, L,1 A SiE <br />Date: /_ IS -6e, <br />