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m <br /> Z Tj <br /> SAN JOAQUIN COUNTY 00 <br /> �r^�,� <br /> ENVIRONMENTAL HEALTH DEPARTMENT m Z � <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 D K z 'fit <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.siaov.orq/ehd � Z — t ' 6 <br /> m y � /' <br /> = m < <br /> RETURN TO COMPLIANCE CERTIFICATION > m <br /> q 0 <br /> Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must tie <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 time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification t0 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 results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: 3/Z7 01 Inspected By: � a <br /> Facility Address: C730 e Ufet w /'2a�cf EPA ID* C 14 s457 <br /> 1 certify under penalty of law that: <br /> 1. 1 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 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 submitting false information, including the <br /> possibility of fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: RRC e_/c G rip Title: (�� Aoc(G GH4� <br /> Signature: Date: <br /> EHD 22.02-005 Rev 04/19/12 <br />