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SAN .JOAQUIN COUNTY "R <br /> ENVIRONMENTAL HEALTH DEPARTMENT DEC <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telep one:(209)468-3420 Fax:(209)468-3433 Web:www.s0gov.org'ft4R NM cj, <br /> RE URN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations n ted 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 30 days of receipt of the <br /> Inspection Report. HSC 25404.1.2(c)(1) <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 30 days <br /> unless otherwise specified in the Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD I staff ti a associated with failing to comply by the above noted dates will be <br /> billed at the cu rent hourly rate. <br /> For this certific tion to be complete the operator of the site must include: <br /> • A statement docum nting what corrective actions were taken or will be taken for each violation <br /> • Copies of sampler sults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying correction <br /> • Operator's certificat on <br /> Inspection Date: p y: y <br /> i � I Inspected B Stacy <br /> Rivera <br /> Facility Address:2-u �; C EPA ID#: <br /> I certify and r penaltof law that: <br /> 1. 1 have c rrected �he violations specified in the Inspection Report from the above-mentioned <br /> inspecti in date. <br /> 2. 1 have personall examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATI N and I believe the information to be true, accurate, and complete: <br /> Photos t--'Paperwork Statement <br /> 3. 1 am aut orized t submit this certification on behalf of the Respondent. <br /> 4. 1 am aw re that t ere are significant penalties for submitting false information, including the <br /> possibilit of a fin and/or imprisonment for known violations. (HSC 25191) <br /> Name: - -+r Title: L �Nat \,I-- C' <br /> Signat �e: /,J,L, Date: <br /> EHD 22-02-005 Rev 09111 <br />