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SAN .JOAQUIN COUNTY "R <br />ENVIRONMENTAL HEALTH DEPARTMENT DEC <br />600 East Main Street, Stockton, CA 95202-3029 <br />e: (209) 468-3420 Fax: (209) 468-3433 Web: www.s0gov.org'ft4R NM cj, <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations rated 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 staff tie associated with failing to comply by the above noted dates will be <br />billed at the cu rent 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 sampler sults/manifests/training records/other appropriate paperwork, and/or photos <br />verifying correction <br />• Operator's certificat on <br />Inspection Date: I � % 1 1 11 <br />Inspected By: Stacy Rivera <br />Facility Address:2C � �• (� i ;)U�CI(,�� C EPA ID#: ,H�, <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 awe that t ere are significant penalties for submitting false information, including the <br />possibilit of a fine and/or imprisonment for known violations. (HSC 25191) <br />Name: �� -+r Title: <br />Signat e: Date: <br />EHD 22-02-005 Rev 09111 <br />