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PUBLIC HEALTH SERVICES <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DIVISION <br />Ernest M. Fujimoto, M.D., M.P.H., Acting Health Officer <br />344 E.Weber Ave., 3rd Floor • P. O. Box 388 • Stockton, CA 95201-0388 <br />209/468-3420 <br />CERTIFICATION OF RETURN TO COMPLIANCE <br />1n the matter of the Violation(s) cited on <br />As Identified in the Inspection Report dated <br />Conducted by <br />(agency or agencies) <br />I certify under penalty -of law that: <br />1. Respondent has corrected the violations specified in the notice of violation cited <br />above. <br />2. 1 have personally examined any documentation attached to the certification to <br />establish that the violations have been corrected. <br />3. Based on my examination of the attached documentation and inquiry of the <br />individuals who prepared or obtained it, I believe that the information is true, <br />accurate, and complete. <br />4. 1 am authorized to file this certification on behalf of the Respondent. <br />5. 1 am aware that there are significant penalties for submitting false information, <br />including the possibility of fine and imprisonment for knowing violations. <br />Name (Print or Type) Title <br />Signature Date Signed <br />Company Name <br />EPA ID. Number <br />A Division of San Jnaquin County Health Care Services <br />