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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www,sigov.org/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br /> corrected 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. a <br /> All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form or <br /> isputes to any violations are to be submitted using this certification and returned to EHD within 30 days <br /> unless of erwise specified'lin the Inspection Report. <br /> Note: All EHD staff tim associated with failing to comply by the above noted dates will be <br /> billed at the curr nt hourly rate. <br /> For this certification t0 be complete the operator of the site must include: <br /> • A statement documen ing what corrective actions were taken or will be taken for each violation <br /> • Copies of sample res Its/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: 2i- 2-4 ' (D Inspected By: 6AP*-C-_Tr ?0C-tC-115 <br /> Facility Address: 2,3001 e. �-_V4TMtLE-_ FcAp EPA ID#: CAT08002(ol�20 <br /> i <br /> I certify under penalty of law that: <br /> 60NTE!i- <br /> 1. I tho 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 /> -_Photosy Paperwork V1 Statement <br /> 3. 1 am authorized to s�bmit this certification on behalf of the Respondent. <br /> 4. 1 am aware that ther are significant penalties for submitting false information, including the <br /> possibility of a fine nd/or imprisonment for known violations. (HSC 25191) <br /> Name: Title: 1JIC�pfJ1`�(�f.1 <br /> Signature: Date: 4- 2vlo <br /> EHD 22-02-005 Rev 10/09 <br />