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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone.(209)468-3420 Fax. (209)468-3433 Web:www.sjgov.or ehd <br /> CERTIFICATIONRETURN TO COMPLIANCE <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(ED)address at the top of this form 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 60 days <br /> unless otherwise specified in the <br /> Or this ce l Cat1O to be COMP,letethe 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/m felts/trai g records/other appropriate paperwork, and/or photos <br /> w verifying corrections , <br /> • Operator's certification <br /> Inspection Date: inspected y: <br /> Facility Address: EPAID#: <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. , 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLA'T`ION 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. -1 am aware that there are significant penalties for sbmittingfalse information,including the <br /> possibility of fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: Title: <br /> Signature: Date: <br /> VL n 11 M nAc, Ute.,AC/A7 <br />