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SAN JOAQUIN COUNTY 40 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stoqkton, CA 95202-3029 <br />Telephone: (209) 468-3420,Faip (209),468-3433 Web. www.s4qov.or_q/ebd <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. Thi s 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 />Note: All EHD staff time associated with flal., ling to comply by the above noted dates will be <br />billed at the current hourly rate. <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/traininq re; cord : s/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Oporator's certification <br />Inspection -Date: Inspected By: <br />Facility Address: EPA ID#: <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 tobe true, accurate, and complete: <br />Photos Paperwork Statemen) <br />C I am authorized to submit this certification on behalf of the Responderi <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 />Name: —Title: <br />Em <br />EHD 22-02-005 Rev 10109 <br />Date: <br />