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SAN JOA40N COUNTY <br /> � ' NVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> 11, <br /> Telephoner(209)468-3420 Fax. (209)468-3433 Web: 'siQov.or ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINO violations noted in the"Notice to Comply"in the attached inspection report must be <br /> correctedwithin 30 days of receipt of this inspection. This;certifitation form must beFs bmitted to the . <br /> Environmental Health Department( ) address,at the top of this form,within 35.days of receipt of the <br /> insp ecti6hrepoit. <br /> All corrections to other,yiolatio ,notedin the attached Inspection , eport{i )or Cp tipuatzo Form,,or <br /> disputes to y violations, a e submitted using this certification d;returned to,E within 60 days <br /> unless bihe rWise specified'in't 'e <br /> gFor this certificationthe operator of the site must include. <br /> A statement' documenting what corrective actions were'taken or will b6.1aketi=for each.violation <br /> Copies of sample results/manifests/training records/other appropriate paperwork, d/orpoto5 <br /> verifying corrections <br /> Operator's certification <br /> Inspection ate: Inspected y: <br /> Facility ss: <br /> - <br /> i certify under penalty of,law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-menti6ned <br /> inspection date. <br /> l <br /> 2. I have personally examined jthe following documentation submitted as proof`of compliance FOR <br /> EAC. . VIOLATION and I believe the information to bet e, accurate, and coe: <br /> mp <br /> . , <br /> Photos Pape or Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> . 1 am aware-that there are si ifi"cant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for A own violations. (HSC 25191) <br /> Name: Title: <br /> Signature: ate: <br /> EHD 22-02-005 Rev 05/07 <br />