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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Teleph ne:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.ora/ehd 118C <br /> RET RN TO COMPLIANCE CERTIFICATIOIQvv/RpN 4 2015 <br /> ME C <br /> Any MINOR violations not d in the "Notice to Comply" in the attached Inspection Reportmustbe R�/Ss <br /> corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Dep rtment (EHD) address at the top of this form within 30 days of receipt of the <br /> Inspection Report. HSC 2 404.1.2(c)(1) <br /> All corrections to other viol tions noted in the attached Inspection Report (IR) or Continuation Form, or <br /> disputes to any violations, re to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified n the Inspection Report. HSC 25185(c)(3) <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 t{11S Certlficat 011 t0 be completethe operator of the site must include: <br /> • A statement document ng what corrective actions were taken or will be taken for each violation <br /> • Copies of sample resu is/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Dat-e: U Inspa:'Crag o r' <br /> moi) <br /> Facility Address: ��14 i✓( D5WO + EPA ID#: C L 1p 33� <br /> certify under penalty o 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 ex mined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION nd I believe the information to be true, accurate, and complete: <br /> Photos Paperwork X 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 at da//or imprisonment for known violations. (HSC 25191) <br /> rr�� <br /> Name: V�� `� �J Title: �-Aj <br /> Signature: Date: /��( Zcrs­ <br /> EHD 22-02-005 Rev 9/11 <br />