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~ SAN JOAQUIN COUNTY 1 <br />ENVIRONMENTAL HEALTH DE=PARTMENT s <br />600 feast Main Street, Stockton, CA 95202-3028 " <br />Telephone: (209) 4683420 Rax: (209) 468-343: Web, <br />RETURN TO COMPLIANCE CERTIFICATrON. ,.0';GOUNF' <br />Any MINpS violations noted in the "Notice to Comply" in the attached Inspection ReportUMEmust'beNT <br />corrected �nrithin 3� 0—days of receipt of this inspection. This certification form must be submitted to the <br />Environmental Health Department (EHD) address at the top <br />Inspection Report. of this form within 30 days of receipt of the <br />All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes t) any violations, are to be submitted using this certification and returned to EHD within 30 days <br />unless otherwise specified in the Inspection Report, — <br />Note: Ali EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate. <br />For thira Certification to be Complete the operator of the site must include: <br />• A statement documenting what corrective actions were taken or will be taken 1br each violation <br />• Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspectioa Date: 1/0 Inspected By:—'ft�' 1T� <br />Facility Address: jj��G.;�.j- j, <br />�'!1�"I� EPA 10#: ( L (Tv 33 4 .?-o <br />I 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: <br />`Photos Paperwork _ Z�Statement <br />3. 1 am authorized to submit this certification on behalf of the Respondent. <br />4. 1 am aware that there are significant penalties for submittinq false information, including the <br />Possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />Name:_ )TC -1 K; i� S . pipe1'�^l.� I <br />Title: .� <br />Signatu -e: <br />Date: jl-2 lb <br />END 22-02.005 Rev 10108 <br />