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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3 Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si`gov.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 (F -HD) 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 600 days <br />unless otherwise specified in the IR. <br />For this certification t0 be complete the operator of the site must include: <br />• A statement documenting what corrective actions were taken or will be taken for each violation <br />s Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />® Operator's certification <br />Inspection Date: �dr �� Inspected By: <br />Facility Address: -�`pue EPA ID#: (", PL O =2610 G kj _-'5� <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 Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. 1 am aware that there are significant penalties for submitting false information, including the <br />possibility of a fine and/or imprisonment for known violations. (FISC 2519 1) <br />Name: --- Title: :5 4. 5 er v i c s <br />Signature: <br />4v % o <br />9/aaw--,. <br />Date: 15/5/0 <br />EH ' d'-026 [tZ' 0N� 12-04 WNE 6-60Z ' dSNVE ECA Wd9 l : Z 6002 '9 'M <br />