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SAN J AQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E. Main St. Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 F (209)468-3433 Web:www.sigov.orpJehd <br /> RETURN TO COMP IANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice toComply" 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) addres i 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 att ched Inspection Report or Continuation Form, or <br /> disputes to any violations, are to be submitted usi g this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Repo . <br /> Note: All EHD staff time associated with failir g to comply by the above noted dates will be billed at <br /> the current hourly rate ($115). <br /> For this certification t0 be compI to the operator of the site must include: <br /> e A statement documenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample results/manifests/traini g records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: b Inspected By: <br /> Facility Address: e- ( EPA ID#:CAg fib' <br /> I certify under p nalty of law that: <br /> 1. I have corrected the violations specified it 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 in rmation to be true, accurate, and complete: <br /> Photos I Paperworky Statement R F G E I EL ' <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penal ies for submitting false information, includingth� 2 20 5 <br /> possibility of a fine and/or imprisonment 1br known violations. (HSC 25191) PNVIRONME TA, <br /> ��t �i1Cfl1 T1�T1CG��?T ,SCAIT <br /> Name: Title: lI�ct�. p,01 A€1,cl, <br /> ZZL7 X \/-I'— <br /> Signature: Date: <br /> EHD 22-02- 5 Rev 10-0 <br />