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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. (2G9) 468-343-3 Web: www.sjgov.o[g/ehd <br />RETURN TO COMPLIAN.CE CERTIFICATION <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 form wn 30 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 bz <br />billed at the current bourly rate. <br />For -this certification to be completethe operator of the site must include: <br />e - A statement documenting what corrective actions were, taken or will he -taken for each violatioln <br />Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />-Inspection Date: Inspected By: <br />M -MM <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />I 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: <br />-Photos Paperwork Statement <br />r• 1 <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. (HSC25191� <br />Name: Title: <br />EHD 22-02-005 Rev 08/08 <br />=3 <br />