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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPAHTMEN i <br /> r: )C1 East lAain Street, Stockton, CA 95202-3029 <br /> Te/ep one:(209) 468-;;420 Fax:(209) 468-3433 Web:ww%vvS; cv-orhd <br /> �< <br /> RE URN TO COMPLIANCE CERTIFICATIt�NpFAM?SFT''�y <br /> Any MINOR violations n ted in the "Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 days f receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health De artment (EHD) address at the top of this form within 30 days of receipt of the <br /> inspection Report. HSC 5404A.2(c)(1) <br /> All corrections to other v16lations noted in the attached Inspection Report(IR) or Continuation Form, or <br /> disputes to any vlolationsl, are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff t4pe associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification t0 be complete the operator of the site must include: <br /> . A statement documenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample results/manifests/training recordslother appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> lnspaction Cate: j)IZply Inspected Sy: T{: <br /> Facility Address:--N I D5WO EPA ID#:� <br /> I Certify under penalt of law that: <br /> 1. 1 have corrected the violations specified in the inspection Report from the above-mentioned <br /> inspection date. <br /> 2. .l have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOL.ATIO� and I believe the information to be true, accurate, and complete: <br /> `! Photos ✓ Paperwork ✓ Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. f am aware that thiere are significant penalties for submitting false information~, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: u � - <br /> . <br /> Signature: Date: <br /> EHD 222-02.005 Rev 811' <br />