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J <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E.Main St.,Stockton,CA 95202-3029 <br /> Tele hone:(209)468-3420 Fax:(209)468-3433 Web:www.s,] og vor <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations n ted in the"Notice to Comply"in the attached Inspection Report must be <br /> corrected within 30 days f receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health De artment(EHD)address at the top of this form within 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to other v olations noted in the attached Inspection Report 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 specifie in the Inspection Report. <br /> Note: All EHD staff ti a associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate $125). <br /> For this certiflca 1011 t0 be Complete the operator of the site must include: <br /> • A statement doc enting what corrective actions were taken or will be taken for each violation <br /> • Copies of sampl results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying correct ons <br /> • Operator's certif. ation <br /> Inspection Date: Z o I Inspected By: MM T�� <br /> Facility Address: 18 00 COXAk "kaj EPA ID#: t�c�o��t Y43 <br /> I certify under penal y of law that: <br /> 1. I have corrected he violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personall examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLAT ON and I believe the information to be true,accurate, and complete: <br /> Photos ,Paperwork ,Statement <br /> 3. I am authorized o submit this certification on behalf of the Respondent. <br /> 4. I am aware that ere are significant penalties for submitting false information, including the <br /> possibility of a in, and/or imprisonment for known violations. (HSC 2519 1) <br /> Name:6 11,ielk-1 Title:?Aa Akk . 54 <br /> Signature: — Date: �{ <br /> EHD 22-02-005 Rev 08 10 <br />