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. <br /> SAN JOAQU/NCOUNTY <br /> ENVIRONMENTAL HEALT* DEPARTMENT <br /> GO0East Main Street, Stockton, CAQ5202'3U29 <br /> Telephone: (20A)4O8-3420Fax:(2Og)488-3433Web: <br /> ������� ��� �������� ������� ����Q�����8/�� <br /> RETURN��"�"� ° �� COMPLIANCE CERTIFICATION <br /> "~���" =~~~� <br /> Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 days ofreceipt ofthis inspection. This certification h»nn.mustbesubmitted hothe <br /> Environmental Health Department(EHD)address at the top of this form within 30 days of receipt of the <br /> Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other violations noted |nthe attached Inspection Report (IR)orContinuation 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 inthe Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> or this certification to be comp/ef <br /> e the operator ofthe site rnunt include: <br /> • Kstatement documenting what corrective actions were taken or will betaken for each violation <br /> w Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: 2_- Inspected By:Stacy Rivera <br /> I certify under penalty of law that: <br /> 1. 1 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 VIOLATION 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 submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Signature: Clate: <br /> exacn'm'uonRev um/1 <br />