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1211012005 03:59 #1153 P.002 /008 <br />UN'40AQUIN COUNTY <br />ENVIRONMENTAL HEALTH DePARTMENT <br />600 East Main street, stockton, CA 95202-3029 <br />TelepDoha: (209) 468=3420 Fax. (209) 468-3433 We& Www.sigov,om slid <br />RETURNTO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the 'Notice to Comply" in the attached Inspection Report must be <br />006!ia;d—within 30 days of receipt of this inspection, This certification form must be submitted to the"r" <br />Environmental Health Department (EHD) address at thd.top of this form within 30 days of receipt of the <br />Inspection Report. <br />All corrections to other violations notd in the attached Inspection Report (IR) or Continuation ForR or . <br />disputes to any violations, are to be submitted using this certification and returned to EHD wftni6days <br />unless otherwise specified in the Inspection Report. <br />Note: All EHD staff time'. assoc-ia- ted with failifi <br />n ^11 be <br />g -:to comply by the above noted dates VA <br />billed at the current hourly rate. <br />For this certification to 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 />Inspection Date: ­ <br />!ns pected By: <br />FajoilityrAddress: i2-:)ol JJ40 k1AA PA ID #: <br />I certify under penalty of law that: <br />have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection daW. <br />2; 1 have Personally examined the following.0ocmentation submitted as proof of compliance FOR <br />.EACH VIOLATION and I believe the' information: to be true, accurat and complete: <br />7 <br />--_—__-,Photos —paperwork Statement <br />3. 1 am authorized.to submit this certification on behalf of the Respondent. <br />4. .1 am away tha there are significant penalties for submitting false information, including the <br />possibili 'of fine and/or imprisonment for known violations. (F <br />RC 25191) <br />Nam 0 1 nAe- Title - <br />signature: Date: <br />EHO 22-07-0045 RAv nRIOR <br />