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SAN JOAQUIN COUNTY n "� \u L9 <br />ENVIRONMENTALdHEALTH DEPARTMENT JAN � � 20Ob' <br />304 East Weber Avenue, 3 Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj2ov.orWehd ENVIRONIVIEN i HEALTH <br />PERMIMSERVICES <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 otheMise 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: 1/ 1 131/26_6s Inspected By: M; 6h,11e Lc , <br />Facility Address: 290 Sp re c ,0c s Ave. EPA ID#: C A L Q0 D 2 S 0 3 1j <br />jean+ccq <br />I certify under penalty of law that: <br />I have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />have person►y cxaiiatnc :. she �viiGw,rig documentation submitted as proof _ compliance F <br />OR <br />EACH VIOLATION and I believe the information to be true, accurate, and complete: <br />Photos __,X_Paperwork _Statement <br />3. I 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 25191) <br />Name: .CAU <br />Title: <br />NJ I L nv vo;j, Carnal,gtjzr Mv, <br />Signature: _)e h R I <br />`1 w�u wv'` �� <br />_ <br />Date: <br />1 " Z <br />EHD 22-02-005 Rev 12-04 <br />