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SANJOA- UIN <br />Q 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.sjgov.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 35 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 60 days <br />unless otherwise specified in the IR. <br />For this certification t0 be Complete the 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 />Inspection Date; 8-1-1,7-6e Inspected By: <br />Facility Address: // 153 IlyceLd &J. � � EPA ID#: - CR L 6 ©O a Y S q3 / <br />7440 j , C4 75376 <br />I certify under penalty o law that: <br />e+t vi LL h.%vis C0+4@e.WZ4Wd`14h*0 91 Octw w SC %s P-414~-0) <br />1. I have corrected .4he violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. I 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. I 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 2519 1) <br />Name: /�li�c4- ���92 V��L� Title: <br />�k <br />Signature: �4,t oswq TNo . Date: <br />F.Hn ��_m_nns uP., nSm� <br />