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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 E. Main St., Stockton, CA 95202-3029 <br />(209) 468-3420 Fax: (209) 468-3433 Web: www.sijzov.org/ehd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations no ed in the "Notice to Comply" in the attached Inspection Report must be <br />corrected within 30 days o 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 35 days of receipt of the <br />Inspection Report. <br />All corrections to other violations noted in the attached Inspection Report 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 billed at <br />the current hourly rate ($105). <br />For this certification t0 be completethe operator of the site must include: <br />• A statement docuir 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 correctio s <br />• Operator's certificEtion <br />Inspection Date: .2 <br />Inspected By: �,gv <br />8 <br />7 - <br />Facility Address: <br />EPA ID#: -W 3/ 9'9,2 D36)2107 <br />I certify under penalty <br />of law that: <br />1. I have corrected the <br />violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. I have personally examined <br />the following documentation submitted as proof of compliance FOR <br />EACH VIOLATIO <br />14 and I believe the information to be true, accurate, and complete: <br />' Photos L� Paperwork ✓ Statement <br />3. I am authorized to <br />ubmit this certification on behalf of the Respondent. <br />4. I am aware that theie <br />are significant penalties for submitting false information, including the <br />possibility of a fine <br />and/or imprisonment for known violations. (HSC 25191) <br />Name: -lv <br />% r 5 Title: /:_1%6.42) �P�s gra Tam is <br />Signature: <br />Signature: <br />41 Date: y ' D a/ <br />EHD 22-02-005 Rej1_07 <br />