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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)46&3433-Web:www.sictov:ora/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 /> i <br /> -Environmental Health Department(EHD)address at the top of this form within 30 days of receipt of the <br /> { tnspection Report. <br /> All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br /> 4 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 <br /> billed at the current hourly rate. <br /> For this certification t0 be Complete the operator of the site must include: - <br /> e 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 /> j Inspection Date: 5 26 tm a Ia Is Inspected By: M WC <br /> Facility Address: 1000 W 4491k TW4 N- EPA ID#: <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. 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 /> i <br /> j Photos Paperwork Statement <br /> i <br /> M <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> f 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 /> ---i DD <br /> Name: bvTc t�abS� Title: .��-W <br /> i <br /> Signature: Date: <br /> —� EHD 22-o2-005 Rev 08108 <br />