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SAN JOAQUIN COUNTY , <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 ��q <br /> Tele hone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> Y v>7V0 ' <br /> RE URN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations oted in the"Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 da of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health epartment(EHD) address at the top of this form within 30 days of receipt of the <br /> Inspection Report. HS 25404.1.2(c)(1) <br /> All corrections to other solations noted in the attached Inspection Report(IR) or Continuation Form, or <br /> disputes to any violatio s, are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specif d in the Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff me associated with failing to comply by the above noted dates will be <br /> billed at the c rrent hourly rate. <br /> For this certifi tion to be complete the operator of the site must include: <br /> • A statement docu enting what corrective actions were taken or will be taken for each violation <br /> • Copies of sampler sults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying correction <br /> • Operator's certifica ion <br /> 01 ' 9 <br /> Inspection Date: Inspected By: <br /> Facility Address: EPA ID#: <br /> certify under penal y 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 personall examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATI N and I believe the information to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3. 1 am authorized submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that ere are significant penalties for submitting false information, including the <br /> possibility of a fi a and/or imprisonment for known violations. (HSC 25191) <br /> Name: ' AS:!A;i"b f K 64 1 i�„�- Title: �t�t��u�` <br /> Signature: " _ Date: 1 s <br /> s6 7 w <br /> EHD 22-02-005 Rev 4172 <br />