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4 SAN JOAQUIN COUNTY 46 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />TeleF)ona: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />RETURN TO COMPLIANCE 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 within 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 be <br />billed at the current hourly rate. <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 />certITication <br />Inspection Date: 0- .2 3 — 0 <br />Facility Address: <br />I certify under penalty of law that: <br />Inspected By: <br />EPA ID#:\�'�lc�G <br />JAN 2 (9 1009 <br />I have corrected the violations specified in the Inspection Report from the til�ilb��I-TI-i <br />inspection date. 1121-51/68 QERPIIIT/S�RVk S <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. (MSC 25191) <br />Name: Title: <br />J <br />Sianature: <br />EHD 22-02-005 Rev 08/08 <br />Date: <br />