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PUBLIGOIJEALTH <br /> SERICES <br /> SAN JOAQUIN COUNTY <br /> t, <br /> ENVIRONMENTAL HEALTH DIVISION <br /> W. <br /> Ernest M M. Fujimoto, M.D., M.P.H., Acting Health Officer <br /> 304 E.Webe Ave., 3rd Floor • P. O. Box 388 • Stockton, CA 95201-0388 c .. <br /> 209/468-3420 <br /> CERTIFICATION OF RETURN TO COMPLIANCE <br /> In the matter of a Violation(s) cited on ��A <br /> As Identified in the Inspection Report dated <br /> Conducted by -_ (agency or age,icies) <br /> I certify under penalty of law that: <br /> 1. Respondent has corrected the violations specified in the notice of violation cited <br /> above. <br /> 2. 1 have per onally examined any documentation attached to the certification to <br /> establish that the violations have been corrected. <br /> 3. Based on rny examination of the attached documentation and inquiry of the <br /> individuals ho prepared or obtained it, I believe that the information is true, <br /> accurate, a d complete. <br /> 4. 1 am autho ' ed to file this certification on behalf of the Respondent. <br /> 5. 1 am aware that there are significant penalties for submitting false information, <br /> including the possibility of fine and imprisonment for knowing violations. <br /> �� �� ��� ✓� rl f <br /> Name (Print or Ty e) Title �— <br /> Signature Date Signed <br /> Company Name EPA ID. Number <br /> A Division of San Joaquin County Health Care Services <br />