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0 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT RECEIVcD <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:.www.sjgov.or /ehd DEC 2 8 20 i' <br /> QAM Inan, <br /> EIMRONMENTAI <br /> RETURN TO COMPLIANCE CERTIFICATI 6WIEPA EN!. <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 fonn within 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to other violations noted in the attached Inspection Report(IR) 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($122). <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 records/other appropriate paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: AOr 2-3r, go/a. Inspected By: e.-ffre- �Q J <br /> Facility Address:Z ;f, EPA ID#: CA L 00 <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I 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 /> Photos Paperwork { Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. I am aware that there are significant penalties for submitting false information, including the <br /> possibility of fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: ZL4 1'� <br /> Title: ' <br /> Signature: Date: I� <br /> EHD 22-02-005 Rev /10 <br />