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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton,California 95205-6232 <br /> Telephone.(209)468-3420 Fax:(209)468-3433 Web:www.sigov.ors/eh <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 da s 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. HSC 25404.1.2(c)(1) <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 dans <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 /> 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 /> • Copies of sample results/manifests/training recordslother appropriate paperwork, andlor photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date; LA �2e, ILA Inspected By: ��k�v� `Iffin <br /> Facility Address: EPA IDf#:CA <br /> � �^, r7 �`► <br /> certify under penalty of law that: <br /> 1. t have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. l 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 Vit, 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 andlor imprisonment for known violations. (HSC 25191) <br /> Name: �. .� k Title: ` :a �ti1 � <br /> Signature: Date: ;: 2!A <br /> EHD 22-02-006 Rev 4112 <br />