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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.(209)4683433 Web:www.siaov:oralehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MING 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 tjof this form within 30 days of receipt of the <br /> Inspection Report. <br /> All corcections to oth,ur violatinns noted in the attached Inspection Report(IR) or Continuation Form; or <br /> disputes to any violations, are to be submitted using this cert cation and returned to EHD wits in 3� days <br /> unless otherwise specified in the InspecGon 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 to be Complete the operator of the site must include: <br /> . A statement documenting what corrective actions were takentor will betaken.fpr each violation <br /> • Copies of sample results/mandests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> . Operator's certifleation tt���� I / <br /> in ectlo��n.Date: �'! Z�/D Inspected <br /> sp 8y: IYIi elle r. <br /> Facility Address: !9(ct) i.J- EtW ST;�!'u EPA Itl#; CAR000 �zN 3aS <br /> I certify under penalty of law that: <br /> 1 I have corrected the violations specified in the inspection Report from the above-mentioned <br /> inspection date. <br /> roof of <br /> 2. I have VIOLATION and I believe theexamined the Vnformat n totation submitted asbe true, accurate, and complete:pitance FOR <br /> EACH � <br /> Photos---Zpaperwork 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. (HSC 25191) <br /> Name: u�r f'esTitle: / <br /> Signature: C .'_ Date: -•?( �r Q <br /> EHD 22.02-005 Rev 08108 <br />