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Mar. 1. 2012 10.06AM TU" FOOD SERVICE No. 6426 P. 1 <br /> SAN roAQYJIN COUNTY <br /> ENVIRONMENTAL.H$ALTII DEPARTMENT <br /> 600 E.Main St.,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sj¢.ov.orsdehd <br /> R111,TUR.N TO COMPLIANCE CERTIFICATION <br /> Any MINOR violatiops noted in the"Notice to Comply"in the attached Inspection Report must be <br /> corrected within 30 d of receipt of this inspection. This certification form must be submitted to the <br /> Environmental HealDepartmeut(EHD)address at the top of this form within 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to.othr violations noted in the attached Inspection Report or Continuation Form, or <br /> disputes to any violators, 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 EIRID staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly r to ($120. <br /> For this Certifi ation to be complete the operator of the site must include: <br /> 0 A statement d cumenting what corrective actions were taken or will be taken for each violation <br /> • Copies of s le results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> Operator's cerification <br /> inspection bate: 1 Inspected By:_01U� <br /> Facility Address: EPA W#: (,,--/W 0 N06 3 a'O <br /> I certify under p ty of law Haat.. <br /> 1. I have correct the violations specified in the Inspection Report from the above-mentioned <br /> inspection date <br /> 2. I have persona ,y examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLAON and I believe the information to be true,accurate,and complete: <br /> Photos Paperwork Statement . <br /> 3. lam authorized to submit this certification ori behalf of the Respondent. \ <br /> 4. I am aware thatere are significant penalties for submitting false information,including the <br /> possibility of a ge and/or imprisonment for known violations.(HSC 25191) <br /> Name; 600,014� Title: et550(1, 5tlp, CSF � S <br /> f� <br /> Signature: Date: 3ft Z <br /> EHD 22-02-005 Rev 08/1 <br />