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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Te[ephppe:(209)4683420 Fax;(209)46$-3433 Web:www.s' ov.or <br /> -9,9T T,9�'viy <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�eceipt 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. i <br /> All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br /> disputes to any violations, a e to be submitted using this certification and returned to EHD within 60 dans <br /> unless otherwise specified in the IR. <br /> For this eertiflcatin to be complete the operator of the site must include: <br /> • A statement ocumenting what corrective actions were taken or will be taken for each violation <br /> verifying co ection: <br /> • Operator's ificat on <br /> Inspection Date: �i� l.ab Inspected By: j�gjte Com' <br /> Facility Address: ; S M 11#&PA ID#: C►i 1- wo -30' J(v +�- <br /> I certify under penalty of law that: <br /> I. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have perso ally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIO TION and I believe the information to be true, accurate, and complete: <br /> _Photos ✓ Paperwork /acStatement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. lam aware t there are significant penalties for submitting false information, including the <br /> possibility of fine aid/or imprisonment for known violations. (HSC 25191) <br /> Name: itle: 0ht 711► Al &ryZI, <br /> c P 0; <br /> Signature: Date: 6 <br /> EHD 22-02-005 Rev 0.5/07 <br />