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.002454 <br /> a_ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 800 East Main Street, Stockton,CA 95202-3029 <br /> Te% one:(209)488-3420 Fax:(209)468-3438 Web:vww.sIaov.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 /> correctdd within 30 days of receipt of this inspection. This certification form must 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 j <br /> disputes to tiny vloletidlld, 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 EHO staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> . I <br /> For this certification to be complete 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/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: i Inspected By: I <br /> Facility Address:�� � �oEPA ID#: L �.(/1 2017 <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 /> Photos Paperwork_Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> I <br /> 4 1 am aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine/and�/gr imprisonme t for known violations. (HSC 25191) <br /> Name: �7 t�'!`r �p� Title: <br /> Signature- -! f' Date. <br /> z• .., <br /> EHD 22-02.000 Rev 08106 SEP " S 2012 <br /> SF.NJOAOIiIN GOIJNTY <br /> EN Eti�IfuL <br /> HEAUHUEP4RT' '_NT <br />