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V4/40/4VV 1 14 vi rnA • igjUUL/UU'L <br />SAN JOAou1N COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Te%pyona: (209) 468-3420 Fax. (209) 468-3433 Web: www,siQov.oWehd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any Ifs NQR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected within 30 fats 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 f=orm, 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 falling 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 records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Uoerators <br />Inspection Date: 0Inspected By:__,6rT A"Z,c.a <br />Facility Address:--,, c3j w G,eQ t R& EPA ID#: c -A L- o oo -2. j; 4 9 C _3 <br />I certify under penalty of l'aw 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,informatio6to be true, accurate, and complete: <br />Photos , ✓ Paperwork Statement <br />3. lam 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 />Name: �a.J Title: eaJ. <br />Signature: � Date: o -!r- A <br />