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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3 Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420,F'ax:(209)468-34433 Web.www.sjSov.orj/ehd <br /> RETURNTO 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 35 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 60 days <br /> witless otherwise specified in the TR. <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 /> • Operator's certification <br /> Inspection Date: •" ` s Inspected By: A` '''` '"` <br /> Facility Address: EPA Ill#: c"a�9 a"�° ' o <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioxied <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 PaperworkStatement <br /> 3. I 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 /> Name: QHS- Title: ` <br /> i <br /> Si mature: _ ._. . .... Date.__ ..... _...._..___�. <br /> EHL 22-02-005 Rcv 12-04 <br /> bd Wd60:Z0 s00Z S0 'oa(l 690TE2260E : 'ON 9NOHd aonoI-i cool Iam W08d <br />