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SAN JOAOUIN 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.sigov.org/ehd JUN <br /> 201Q <br /> RIETURN 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 rhust 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 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 to beCO M P Ie a 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/®r photos . <br /> verifying corrections <br /> • Operator's certification <br /> Inspection ate: c l 1-7190)0 Inspected-By: S ey I V-e i'ck <br /> Facility Address- .SJS' cU /J T" T 'brady EPA ID#: k 000, 7 _ <br /> /76 <br /> 1 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 <br /> omplete:Photos Paperwork Statement <br /> 3. I 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 26191) <br /> Name: 'uL � _Title: L <br /> Signature: 1 Date: <br /> 7 <br /> EHD 22-02-005 Rev 40109 <br /> Td wdzb:TO olo? 20 -unr 'ON XUA woaA <br />