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SAN JOAQUIN COUNTY ONVIRONMENTAL HEALTH DEPARTMENT 304 East Weber Avenue,3`a Floor,Stockton,CA 95202-2708 Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/eh ehd --RETURN COMPLIANCE IICATI Any MINOR violations noted in the"Notice to Comply" in the attached inspection report must be corrected within 30 days of receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD) address at the top of this form within 35 days of receipt of the inspection report. All corrections to other violations noted in the attached Inspection Report(IR) or Continuation Form, or disputes to any violations, are to be submitted using this certification and returned to EHD within 60 days unless otherwise specified in the IR. For this certification t0 be Complete the operator of the site must include: • A statement documenting what corrective actions were taken or will be taken for each violation • Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections • Operator's certification Inspection Date: Inspected By: Facility Address: EPA ID#: I certify under penalty of law that: 1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. 2. I have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and I believe the information to be true, accurate, and complete: Photos Paperwork Statement 3. I am authorized to submit this certification on behalf of the Respondent. 4. I am aware that there are significant penalties for submitting false information, including the possibility of a fine and/or imprisonment for known violations. (HSC 25191) Name: Title: Signature: Date: EHD 22-02-005 Rev 12-04