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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sj og v.org/ehd <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 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 35 days of receipt of the <br /> Inspection Report. <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. <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 ($122). <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 /> Ab%,ve��� c - <br /> Inspection Date: G aZo l Inspected By:�1nU�;�U <br /> Facility Address:,;tc,451 M<<lr.,, _Csc�,\o�, EPA ID#:CALovo /y � <br /> I certify under penalty of law that: <br /> Nr- X. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> 05 inspection date. Ex ae�slc t'e��ae5� S \w��.cc� <br /> 0�, ,2,�,Q I have personally examined the following documentation submitted as proof of compliance FOR <br /> lJ' EACH VIOLATION and I believe the information to be true, accurate, 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_.c', ��'.�� Title: �� � e�s,����,\ <br /> Signature: Date: <br /> EHD 22-02-005 Rev 08/10 <br />