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SAN JgAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, StocKtori,-CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:'(209) 4683433 Web:www.smgov.orglehd <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 inspect ian`. 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 /> 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 Repott.. ' <br /> Note: All EHD staff time associated with faili 9 to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification t0 be COmpletp 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/manifestsltraining records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: {�� z-;:!� Inspected By:_.Nil <br /> Facility Address: 117 EPA ID#:_ 64_b eL <br /> 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 personally examined the following doGpmentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the info.'rrrjat�on'tp be true accurate, and complete: <br /> i_,," Photos aperwork statement <br /> 3. 1 am authorized to submit this certification pp t�alf 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 /> 01 <br /> Name:� TKs- / .,� a-yE�'C .Title: <br /> Signature: Date: g 3 c7 <br /> EHD 22-02-005 Rev 10109 <br />