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COUNTY <br /> ENVIRONMENTAL <br /> SAN JOAQUIN <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 96202-3029 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.si4ov.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 /> correcte 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 30 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 /> disputesjto 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 <br /> billed at the current hourly rate. <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 /> • Codes of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: s�f Inspected By: AGGIe �' <br /> Facility Address: f iM 8 i EPA ID#: A? NZ36-SY&� <br /> I certify under penalty of law that: <br /> I <br /> 1. I 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 submitted as proof of compliance FOR <br /> !EACH VIOLATION and I believe the information to be true, accurate, and complete: S <br /> 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 penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Na me- �4�h <br /> Title: <br /> I <br /> b1c nature: Date: f <br /> END 22-02 005 Rev 10109 <br />