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2012-03-15 11 :07 >> 2094683433 P 3/7 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.siyov.org/ehd <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 30 days of receipt of the <br /> Inspection Report. HSC25404.1.2(c)(1) <br /> All corrections to other vi lations 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 specifi d in the Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the c went hourly rate. <br /> For this certific tion 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 sample r sults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying correction <br /> • Operator's certification <br /> Inspectionp Date: Y• <br /> 7 Inspected B :Stacy Rivera <br /> Facility Address: ��(0) S C—/ `Dc" a� EPA ID#: Ck 0002-F7 <br /> 1 certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete:p <br /> Photos 1 Paperwork_ _Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. lam aware that there are significant penalties for submitting false information, including the <br /> possibility of a fi�Ie and/or imprisonment for known violations. (HSC 25191) <br /> Name: t-t' Title:— <br /> Signature:- <br /> itle:Signature: Date: <br /> EK)27-02•oo5 Rev 09111 <br />