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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton,CA 95202-3029 Telep one:(209)468-3420 Fax:(209)468-3 3 Web:www.siizov.or Z 0 U s W r¢J e //V s,Pr e/7//0) RETURN TO COMPLIANCE CERTIFICATION Any MINOR violations noted in the"Notice to Comply" in the attached inspection report must be corrected within 30 days o 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 n the IR. For this certificate Dn to 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 sampler sults/manifests/training records/other appropriate paperwork, and/or photos verifying corrections • Operator's certification Inspection Date: L Inspected By: ,�qa�� e d c l&'5 Facility Address: C l D 7K CC U/ awn EPA ID#: L ow 3 3 S 3 S I I certify under penalty of law that: 1. I have corrected th 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 th re are signific alties for submitting false information, including the possibility of a fin and/ i prisonme t for known violations. (HSC 2519 1) Name: Title: e — Signature: Date: EHD 22-02-005 Rev 05/0