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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> RET 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 Dep nent (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, to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified Mthe 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. <br /> For this Certlf catl n t0 be Complete the operator of the site must include: <br /> • A statement docurnenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample ults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying correctio s <br /> • Operator's certific tion <br /> Inspection Date: (a I ! Inspected By: Moya � <br /> Facility Address: k, R� EPA ID#: C� q7 <br /> I certify under penalty f law that: <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 /> EACH VIOLATION and I believe the information to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. I am aware that th e are significant penalties for submitting false information, including the <br /> possibility of aa'fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: Title: ��U,1�ZinVl�ern1 / St`s-i <br /> Signature: Date: <br />