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SCAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTM13NT <br />304 East Wcbcr Avenue, P Floor, Stockton, CA 95202-2708 <br />Telephoner (209) 468-3420 Pax: (209) 468-3433 Wovb- www-saguv_org cl. <br />RETURN TO 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 64 dates <br />unless otherwise specified in the IR. <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 takers 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 />u, <br />inspection!. •Inspected B 11 <br />Facility Address: EPA ID#: Ca4 L. ab 5 Gb!a Q7-Z- <br />6 <br />'°7Zr6 <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 />2. I 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: <br />Signature: Datc: AW- <br />EHD 22-02-005 Rev 12-04 <br />Ed WdLE:60 900E TE 'unf 2VL8 tib6 60E : 'ON BNOHd 118HS 1NOW82id : WOaA <br />