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SAN JOAQUIN COUNTY <br />ENvatoNMENTAL. I[EAL114 DEPARTWNT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone. (209) 468-3420 Fav (209) 468-3433 Weir. www.sjggv.org/ehd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in lite attached Inspection Report must be <br />corrected within 30 days of receipt of this inspection. This certification form roust be submitted to die <br />Environmental Health Department (EIdD) address at the top of this fonnn within 35 days of receipt of the <br />Inspection Report. <br />All corrections to other violations noted in the attached Enspection Report (IR) or Continuation Forst, or <br />disputes to any violations, are to be submitted using this certification and returned to ERD 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 date=s will be billed at <br />the current hourly rate ($122). <br />For this certification t0 be COl1 plete the operator of the site must include: <br />o 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 />venfymg corrections <br />• Operator's certification <br />hispection Date: O I Inst to By: m% S <br />Facility Address d Z, EPA 1D#: <br />I 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. I have personally examined the following documentation submitted as proof c �L_4 <br />Bance EOR <br />EACH VIOLATION and I believe the information to be tie, accurate, and � L <br />— <br />Photos Pal pork �_O__Sutement T <br />3. I am authorized to submit this certification on behalf of the Respondkxtt. AW 1.9 Za;f j <br />SAN JOAOM, <br />1. <br />4. 1 ant aware that there are significant penalties for submitting false infor ation, inclplll *dW.�rAL <br />possibility of a fine and/or imprisonment for known violations. (HSC 2519 1) HEALTH, DEPAaTUEM <br />Name: - ( r ;(-D, (-t,- Title: <br />Signature: Date: 24"1 <br />ERD 22-024M5e -/ 10 <br />moi' : � L `S IL%ZCt d reA-V_ 4-C <br />0.4y<; Aon4l . <br />0 � � 2L ~ U, C- 5, gn <br />