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SAN JAUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone. (209) 468-3420 Fax: (209) 468-3433 _ _e .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 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 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 submitted using this certification and returned to EHD within 30 days <br />unless otherwise specified in, the Inspection Report., <br />billed at the cAirrent hourly <br />For • to • . complete <br />- operator of - site must include: <br />• A statement documenting what corrective actions were taken or will be taken for each violation <br />• Copies of •le results/manifests/training recorqs/other appropriate paperwork,and/or photos <br />verifying corrections <br />Operator's certificati•, <br />Inspection ate: Ins ecte, <br />Facility Address: EPA 1D#: <br />underI certify 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. 1 am authorized to submit this certification on behalf of the Respondent. <br />1 am aware that there are significant penalties for suf • false information, <br />possibility of a fine and/or• .r known violations.• <br />Name: Title: <br />Signature: ate: _ <br />EHD 22-02-005 Rev 10/09 <br />