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SAN JOAQUIN COUNTY i <br /> ENVIRONMENTAL HEALTH DEPARMENT <br /> 1868.East Hazelton Avenue, Stockton, Cafifdrnia 95205-6232 i <br /> Telephone:(209)468-3420 Fax (209)46$3433 Web:www.siaov.orglehd <br /> ; <br /> s <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR vialatiWo noted in'the"Notice to Comply"in the.attached 16spedtion Report must be <br /> corrected vuithin 30.days of receipt of this inspection. This certification form must.be.submitted to the f <br /> Environmental Health Departrnnent(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 /> All corrections to otheryiglatlons noted in the attached Inspection Report(IR)or Continuation Form, or { <br /> disputes to any violations,-are to besubrriitted using this certification and returned to EFfD within 3{l 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 /> I <br /> i For this certification to be complete the operator of the site must include: <br /> 3 <br /> * A statement documenting what corrective actions were taken or will be taken.for eacfi violation { <br /> * Copies of sample resultslmanifestsltraining records/other appropriate paperwork, and/or photos <br /> i verifying corrections <br /> • Operator's certification 1 <br /> i <br /> Inspection Date:Bgj� 4, a o r 57 Inspected f3y:_±4 s. A.-r h e r l'* He <br /> l �.. <br /> F <br /> Facility Address: I6 14-W 14-d !td IAIA, G4 EPA ID*: CA t7oo919Y Sog � <br /> - l <br /> I cerlify under penalty of law that: i <br /> I <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 documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and i believe the information to be true, accurate, and complete: <br /> Photos Paperwork < Statement <br /> 3. 1 am authorized to subrnit this certification on behalf of the Respondent. <br /> 4. t'am aware that there are slgnificant penalties for submitting false information, including the <br /> possibility of a fine andlor imprisonment for known violations. (HSC 25191) <br /> Name: TO Title: <br /> Signature: �- <br /> Date: <br /> f <br /> r <br /> i <br /> EHD 22-02-Qp5Rev 41i2 1 <br />