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.002454 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600,East.Main:Street, Stockton, CA 95202-3029 <br /> Te/ep'=e:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orQ/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any IU NOR violations noted in the "Notice to Comply" in the attached Inspection Report: must be i <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 j <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 <br /> billed at the current hourly rate. I <br /> i <br /> For this certifieati®n t® be complete the operator of the site must include: � <br /> i <br /> • A.statement documenting what corrective actions were taken or will betaken 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: inspected By: 4IK11's �AcAPI <br /> Facility Address:1700S-eAegakgc-Zm &j, *PA ID#: CSL. 0000256 t <br /> i <br /> I certify under penalty of law that: I <br /> i <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOR <br /> A.EACH VIOLATION and I believe the-information to be true, accurate, and complete: <br /> A _ <br /> Photos X _Paperwork Statement <br /> 3.7 1 am authorized to submit this certification on behalf of the Respondent. <br /> q I <br /> 4; I am 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 /> IN ame: � Title: PARIS <br /> Signature Date oh 0 <br /> j <br /> EHD 22-02-005 Rev 08/08 <br />