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2012-03-21 15:47 5801 TRU 2094662259 2094640138 P 6/8 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Strcct, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Wcb: www.sjgpX&, /gL <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 day-, 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 35 days of receipt of the <br />Inspection Report. <br />All corrections to other vi Iations 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, <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at <br />the current hourly rate (SM). <br />I26 <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: 911(0/1/ <br />Facility Address: <br />I certify under penalty of law that: <br />Inspected By: Stacy Rivera <br />BPA ID#: <br />1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. I 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 __ZPaperwork V' statement <br />3. I am authorized to submit this certification on behalf of the Respondent, <br />4_ I am aware that there are significant penalties for submitting false information, including the <br />possibility of a fine and/or imprisonment for known violations. (HSC 2519 1) <br />Name: Title: ►--� acs /" <br />Signature: Date: /0//(—/// <br />EHD 22-02-005 Rev 08/10 <br />