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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue,Stockton,California 95205-5232 <br /> Tolephona:(209)468-3420 Fax:(209)468-3433 Wob:www.siQov,orWehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the'Notice to Comply'in the attached Inspection Report must be <br /> corrected wtthln 3Q 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 30 days of receipt of the <br /> Inspection Report. HSC 25404.1.2(c)(1) <br /> Ali corrections to_o other violations noted in the attached Inspection Report(IR)or Continuation Form,or <br /> disputes to arty violations,are to be submitted using this certification and returned to EHD within 3Q days <br /> unless otherwise specified in the Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated With failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification to be c 1. plete 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 resuftsfmanifests/Vaining recordslother appropriate paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Bate: 11 o16 I I Inspected By:Clews f oAl-c-,-- <br /> Facility <br /> ,-Facility Address:lr,ei IA/• Cbafkr -,, oy EPA ID#:C_r; .000 HUd6 fi-S <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. 1 have personalty 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 /> � e Photos :�Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penatties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: fAS y I R, �' R! H Title: <br /> :3' nature: Date: <br /> aro 2aa2-M PM 4n2 <br /> 40 6 20,17 <br /> pp 1� gg��� y <br /> E� t7�'�RONIIMt"Elect TAL f"E eL 1 H <br />