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002454 ®- <br /> SAN JOAQUINI COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 ' <br /> Te/ear,'~one:(209)468-3420 Fax:(209)468-3433 Web:www.sigov-orCL/ehd APR <br /> 13 2011 <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 thin 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 i failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> C this certification to be completethe 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 /> Operators certification <br /> lns action ate: , t/ Inspected y: a ® x lr <br /> FacilityC <br /> Address: Lei .A- I C (j-0 IL/ �y <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations speed in the Inspection Report from the above-mentioned <br /> inspection date. <br /> r <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOR <br /> IEACH VIOLATION and I believe the',information-to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> . 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 /> Names- on. , s Title: � c�d <br /> Signature Date' 9 3 I <br /> EHD 22-02-005 Rev 08108 <br />