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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E.Main St., Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.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 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to other violations 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 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 ($105). <br /> For this certification t0 be Complete the operator of the site must include: <br /> • A statement documenting what c e =eill be taken for each violation <br /> • Copies of sample results/manife s' ate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification SEP 02 2011 <br /> SAN JOAQUIN COUNTY <br /> n ENVIRONME 'TAL cted B <br /> Inspection Date: l c�- �-�I HEALTH DEPAA y: <br /> Facility Address: �� Cc Sfi EPA ID#c o ,n on Q 'ss-3 j `i <br /> L_od� Cl� <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. I 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 t/ Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <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 /> Name: �,� , V, Title: O w K-P <br /> Signature: Date: oil b-1do <br />