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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.org/ehd <br />''RETURN -TO COMPLIANCE CERTIFICATION <br />Any'MINOR violations noted in the "Notice to Comply' In the attached Inspection Report mustbe <br />'corrected within 30 days of receipt of this inspectio ' n. This certification form must be submitted to the <br />Environmental Health Department (EHD) address at the top of this form within 30 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 subm ittedusing this certification and returned to EHD within 30 days <br />unless otherwise specified in the Inspection Report. <br />Uri Nw- 1 0 <br />MMO &I [IL-21 I• - '111i <br />ffis <br />For this certification to be completethe 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 />EMEMM03 <br />Inspected By: <br />F*XMIT.'; <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentione4l <br />inspection date. <br />KMAL�dk <br />Photos Paperwork Statement <br />4. 1 am aware that there are significant penalties for submitting false information, including t <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) 1 <br />Name: Title: <br />Signature:._ Date: <br />EHD 22-02-005 Rev 06/09 <br />