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0 <br /> S/,NT,Y0,4QUL1\1 1_-GUNTV <br /> - ?Eta KT _E <br /> INV--- <br /> KONIM EN7 AL HEALTF TIM, -XT <br /> 600 Last Miaill Street, Stockton,CA 35202-3023 <br /> TelepFiGmv (209)468-3420 Fv:: (2091468-3433 ff'cb.-vrvm1.sjgov.org/eh <br /> RETURN TO CGMPLIANCE CERTIFICAMON <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be <br /> corrected within 30 days of receii.-it ofthis -_Inspectlon. This certification -1-orm must be submitted to the <br /> Environmental Health Departnqent- (EHD) address at t e top of this fora, -1-n 35 days of recei-pt of the <br /> Inspection Report. <br /> All gorrect"lons toGislerviolations noted in the attached Inspection Repoft ("IR) or Continivation Form, or <br /> disputes to any violations, are to be submitted using this cer i-fil-castion and.-�tunned.to EHD within 30 days <br /> t-inliess otherwise specified -in the Inspection Report. <br /> Note. All EHD staff time associated with, failing to, comply by t1he abcve nc-fted dates vv,1111 'I--e 'Y"led at <br /> the current hourly rate (S98). <br /> For this certification to be complete ftie operator ondat site rn-ust inchude: <br /> * A statement documenting what corrective actions were taken or will be taken for --ach violation. <br /> * Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> veri&- ing Correctioris <br /> * Operator's certificatiop <br /> F_ <br /> Inspection Date: <br /> ecped By: <br /> Insp <br /> Facility Addrss:6t3�,�,2 1\j `46f4%i <br /> EETIJ.-A ID' #: <br /> I certify under penalty of law that: <br /> ti"Z 4^ 44, 4LW id-ue-arex <br /> 1. I have corrected the violations specified in the inspection Report 1romiffie above-mentioned <br /> inspection date.A <br /> 1 ,I have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be tree, accurate, and complete: <br /> P ,,- <br /> Photos p � enxork /K Statement <br /> C_ a-o <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 /> et <br /> Name: Title: t <br /> Date: <br /> Signature: <br /> 7- / 7- <br />