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% 1 0 <br />0 nr.�rf-_kv!�L <br />San Joaquin County <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, California95205-6232 JUS <br />Telephone. (209) 468-3420 Fax, (209) 468-3433 Web: www.sigov.om/ehd <br />RETURN TO COMPLIANCE CERTIFICOM TI <br />Any MINOR violations noted in the "Notice to Comply' in the attached Inspection Report must be corrected within 30 days of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHID) address, <br />the top of this form within30 days of receipt of the Inspection Report. HSC 254041.2(c)(1) <br />All corrections to other _violations noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any <br />violations, are to be submitted using this certification and returned to EHOwithin 30 days unless otherwise specified in the <br />Inspection Report. HSC 25185(c)(3) <br />Note: All EH ID staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate. <br />For this certification to 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 recordslother appropriate paperwork, and/or photos verifying correctiow, <br />Inspection gate: Ins pectedBy: <br />C A L 000 OLK V,0 <br />Facility Address: EPA Ia. <br />I certify under penalty of law that: <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLA <br />I believe the information to be true, accurate, and complete: <br />Photos Paperwork v"" Statement <br />3, 1 am authorized to submit this certification on behalf of the Respondent. <br />I am aware that there are significant penalties for submitting false information, including the possibility of a fine anc <br />imprisonment for known violations. (HSC 25191) <br />'Zo( <br />Name:— Title: <br />Signature: —Date. 4- <br />