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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.siggy,2 9 <br />RETURN TO COMPLIANCE Y.. • <br />Any MINOR violations noted in the °Notice to Comply' in the attached Inspection Report trust be ' <br />corrected within,30 dpvs of,receipt.of this inspection. This certification form,,ft4t:ti® slabmided to.the <br />Environmental Health Department (EHD) address at the top ®f this form wdtFi $Wdays 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 />�_,... <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 />rr : :. <br />billed at the current hourly rate. <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 />• Copies of sample results/manifests/training recordslother appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date:T -5—,// 7 11iQ Inspected By: Gr R„a< ,i39ckws <br />Q k <br />Facility Address: jsr_< 14*om,we Z t4;4r EPA ID #: CAL, dd 0 OY3 31 <br />5400-04), CR 9 S er q <br />I certify under penalty of law that: <br />1 I have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date <br />2. 1 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 f/ Paperwork Statement <br />3. 1 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. (HSC 25191) <br />Name: Zq,;( cs /`4 q Ld 7`— Title: &A, �C'�.✓ c>. /�% � 2 s <br />Date: <br />END 22-02-M Rsv 10100 <br />