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tjpJ.�RL'df�°'y*i�r{::tit4r..v..v.�car....,•--- - � .+w...V.. - -. _ �_ _ _ _ _ _ <br />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.siaov.ora/ehd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" 1n 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 30 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 certif <br />cation 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 <br />billed at the current hourly rate. <br />For this certification to 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 records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• <br />Operator's certification <br />Inspection Date: Z — d C/ Inspected By: 6;jMC-Tr &e/CN.s <br />Facility Address: 3,9 S5_ EPA ID#: CAL o d a 613 <br />S�d C) <' io , Cit C/ 0/ <br />I certify under penalty of law that: <br />1. I have corrected the violations specked 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 _,,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: /' i kk <br />Title: A," cid �, �' �+! ✓• rte/i4-r2� <br />Date: G - 2 G - d <br />