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0 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.sigoy.orehd <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 dqy&of receipt of this inspection. This certification form mustibe submitted to the <br />Environmental Health 'Department (EBD) 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 />unless otherwise specified in the IR. <br />For this certification to be completethe 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 />• Operator's certification <br />EM7621m3m <br />cmlmyj�� <br />PITMIM <br />IN <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 bet e, 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 />EH1 22-02-005 Rev 05/07 <br />M0 <br />Date: <br />