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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME <br /> 600 E.Main Sr.,Stockton,CA 95201-3029 <br /> ?Telephone.(209)469-3420 Fax:(209)468-3433 Web:www,silioy.oreehd <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 dans 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 violations noted in the attached Inspection Report 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 ERD staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate ($115). <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 /> a Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> o Operator's certification <br /> Inspection Date: '? p f b Inspected By: W.Lj,Jit. 0 s oily <br /> Facility Address: ,�� _W. yv r_ j� AveEPA ID#: AL t"t 3 Z <br /> ry.0au�rZCA , C A Ts 33`l <br /> I certify under penalty of law that: <br /> I-hzr+Fe correct 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 l believe the information to be true,a urate, and complete: <br /> Photos—/—Paperwork 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: L m,. f t,t J G Title: V P <br /> Signature: Date: —) r L7 <br /> EHD 22-02-005 Rely.4,407 <br />