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0 SAN JOAQUIN COUNTY 0 <br /> ENvIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax. (209)468-3433 Web®WWW.sigoy.org/ehd. <br /> U Ll Lt::_ L_ j <br /> __1 r �y L <br /> RETURN TO COMPLIANCE CERTIFICATIONIC, 1 ,9 2008 <br /> -46--ALTH <br /> 4111114,t7e, <br /> Any MINOR violations not in the"Notice to Co ply" in the attached Inspection WWI i, <br /> corrected within 30 days of receipt of this inspection. This certification form must b iu6difffe <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 E within_22_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 baled at <br /> the current hourly rate ($98). <br /> For this certification to 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 /> Inspected By: <br /> Inspection Date: <br /> Facility Address: EAI ##: <br /> I certify under penalty of law that: <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. lain 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 /> Title: <br /> Name: <br /> Date: <br /> Signature: i <br /> EHD 22-02-005 Rev 11/07 <br />