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SAN JOAQUIN COUNTY ' * <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 Fast Main Street, Stockton, CA 95202-3020 <br /> Totephone:(209) 468-3420 Fax:(209)468-3433 Web:vurEW s3Qov oralehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br /> must be submitted to the <br /> corrected within 34 da s of receipt of this inspection-dat the�top eof�this tform ion �withirz 30 days of receipt of the <br /> Environmental Health Department (EHD) ad <br /> Inspection Report. <br /> inuation Forrn, or <br /> All corrections to other violations noted in the attached liis certification ion Bport and reRurrred totEHD�+��n Q da s <br /> disputes to any violations, are t© be submitted 9 <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EMD staff time associated with failing to comply by theabove noted dates will be <br /> billed at the current hourly rate. <br /> For this certification to be complete the operator of the site must include: <br /> . A statement documenting what corrective actions were takers 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 G & d c 5 - 1 - 4 <br /> � d a � I � _ Inspected By: <br /> inspection Date: <br /> Facility Address: ( � u�a EPA 1®#: + .L <br /> I I certify under penalty of law that: <br /> � <br /> 1 . 1 have corrected the violations specified in the Inspection Report frorn the above-mentioned I <br /> . I <br /> �nspectian date. <br /> 2. 1 have personally Il 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 /> —Photos��Paperwork �- #atement <br /> 3. 6 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 25191) <br /> Name- cz " Title: <br /> Signature: Date-. C a <br /> EH❑22-02-OG5 Rev l0l09 <br />