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SAN JOAQUIN COUNTY 9 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 Fast Main Strut. Stockton,CA 95202.3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Wel,: www.szaov ori/c[�_d <br /> RETURN TO COMPLIANCECERTIFICATION <br /> Any MRVOR violations noted in the"Notice to Comply'in the attached .Inspection Report must be <br /> corrected within 30 da s 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 EHl?within 30 dove <br /> unless otherwise specified in the Inspection Report. <br /> Note; All JE. D►staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate ($98). <br /> For tb1S 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 /> Opemtor's certification <br /> Inspection pate: ���t( Inspected By: �}- F` <br /> Facility address:�� � �c � EPA 1:D#: <br /> I certify under penalty of law that: <br /> L I have corrected the violations specified in the Inspection. Report from the above-mentioned <br /> inspection date. <br /> 2. [have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and [ believe the information to be true, accurate, and complete: <br /> Photo% Paperwork--11-16 Statement <br /> 3. [am authorized to submit this certification on behalf ofthe Respondent. <br /> 4. I 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: 1\C.`�.•,c�r,� 411 M�_. Title: 't� <br /> Signature: ® Date: <br /> PUT' 7,)-m-nn. R®,Lr 1 1/M <br />