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SAN JOAQUIN COUNTY <br />ONVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone. (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgqv.oreehd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected Tithin 30 days of receipt of this inspection. This certification form must be submitted to the <br />Ezerirtrcmental Health 3W�zz.-t-m—en 'if tki, <br />Inspection Report. <br />awLies to ffr_101111MRS, A,70 L191 VC SLMUILLCIL <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. <br />For this certification to be completethe 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 />FMT•�� <br />EME <br />M9933� <br />1. I have corrected the 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 FO <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: i <br />4. 1 am aware that there are significant penalties for submitting false information, including the <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />am <br />Si <br />