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0 SAN JOAQUIN COUNTY . <br />ENVIRONMENTAL HEALTH DEPARTMENT ,. <br />600 East Main Street, Stockton, CA 95202-3029 .� ".. <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/e id <br />AUG 16 Znfp <br />SAN JOE°,::Ui!� rOJfY7y <br />RETURN TO COMPLIANCE CERTIFICATION6!E'W, .v�.="Out <br />L7}i C�?,e.r�Tis�r�JT <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 />Operator's certification <br />Inspection Date: <br />Facility Address: <br />I certify under penalty of law that: <br />Inspected By: <br />EPA ID#: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <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 _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. (HSC 25191) <br />Name:<,— /9,:'7'Title: <br />Signature: <br />EHD 22-02-005 Rev 10/09 <br />Date: !2 - 9 - <br />