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0 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (249)468-3420 Fax.(209) 468-3433 Web:www s ov.or lehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations Hated in the "Notice to Comply <br /> " ih the attached Inspection <br /> must be submitted to the <br /> corrected w+thin 3g da s of receipt Of this inspection. This certification <br /> Environmental Health Department(EHD) address at the top of this form within 30 days of receipt of the <br /> Inspection Report_ <br /> Or <br /> carr <br /> corrections to other violations Noted in the attached inspection Report fRumed Continuation <br /> EHO within Form, <br /> diclaws <br /> disputes to any violations, are to be submitted using this certification and <br /> unless otherwise specified in the Inspection Report, <br /> Note; Ail 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 Coniplete th operator <br /> r for of the site be takefor st incl dolatian <br /> . A statement documenting what corrective actions were taken <br /> . Copies of sample results/manifestsAraining records/other appropriate paperwork, andlor photos <br /> verifying corrections <br /> . operator's certification <br /> Inspection Date: <br /> � inspected By: o. <br /> Address= EPA 1D*' <br /> Focality CO 3 o <br /> I certify under penalty of law that: <br /> 0Ihave corrected the violations specified in the Inspection Report from the above-mentioned <br /> 0 <br /> inspection a date. <br /> d as <br /> proof of <br /> e following documentation obetrueu accu�ate and a $pliance FOR <br /> 2. 1 have personally examined th <br /> EACH VIOLATION and I believe the information <br /> -PhotosPaperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondeat. <br /> 4. I am aware that there are significant penalties for submitting false infor ga;ion, including the <br /> possibility of a fine and/or imprisonment for known violations. (H ) <br /> w-P+L-- Title. C� <br /> Date-, <br /> 51g <br /> nat�ire:c -�1 Date-, �9 a � 1� <br /> EHD 22-02.005 Rev 10/09 <br />