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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTM10 <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siaov.org/ehd <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 d ays of receipt of this in . spection. 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 ed Inspection Report (IR) -or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 30 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 <br />billed at the current hourly rate of $1,05 (beginning 8/11/09 the hourly rate will be $115). <br />For this certification to'be cbmpletethe operator of the site must include: <br />A statement -documenting What corrective actions -were taken or will ben for each,violation <br />Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />,i Operator's certification <br />Inspection Date: Inspected By: <br />Facility Address: EPA ID#: <br />I certify under penalty of law that: <br />1 1 have corrected the violations specified in the Inspection Report from the abov &-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. 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 />"M <br />Signature: Date: <br />EHD 22-02-005 Rev 06/09 <br />