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052454 <br />.SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600, East Main Street, Stockton, CA 9520: <br />Talep:!one: (X18)468-3420 Pax: (209) 468-3433 Wets., dw.s ov. r 1 hd <br />RETURN TO COMPLIANCE CERTIFICATION <br />AnyIM NOR. violatlons noted in the "Notice to Comply" in the attached Inspection Report must be <br />cmected within 30days of receipt of this inspection. TMs certification form must be submitted to the <br />Environmental Health Department (END) address at the top of this fomi within 30 days of receipt of the <br />Inspection Report. <br />A11 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, <br />M10ta: All EH,D atafif time associated vAth t'alling tto comply by the above noted dates Lvill bo <br />billed at the current hourly rate. <br />For this certification to be complete the operator of the site must include: <br />• A staternent documenting what corrective actions Were taken or will be taken for each violation <br />Coples of sample results/rnanifestsEtraining records/other appropriate paperwork, andlor photos <br />?rifying corrections <br />. Operator's certification <br />spection Da.#e: �� , (�`fi � � %� Inspected By; V`r i 015 <br />Facility Address:/ r "= J ei—o& A • EPA ID#: t, 6� <7 27/ <br />I ce7tify 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 st bmitted as proof of compliance FOR <br />EACH VIOLATION and i believe thwinformatlon-to lie true, accurate, and complete: <br />Photos PaperworkStatement <br />3, 1 am authorized to submit this certification on behalf of the Respondent. <br />4 lam aware that there are sign Iffcant penalties for submitting false information, including the <br />pc,sslbility of a fine andj/or Imprisonment for known violations. (HSC 25191) <br />Name: '� �c S <br />nature, (i J", _ .r- G,14,_ Date, l <br />EHG �_2-02.005 Rev DBW <br />