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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)4:68-3433 Web:www.sioov.org/ehd <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 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. <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 Report. <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 corn, pl0q, the operator of the site must include: <br /> • A statement documenting what corrective actions uVere taken or will be taken for each violation <br /> • Copies of sample results/manifests/training'rocordsIother appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: Inspected By: <br /> Facility Address: EPA ID#: <br /> certify under penalty of law that: y!, <br /> 1. I 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 submit this certification on behalf of the Respondent. <br /> 4. lam 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: fr'u S Title: �Ni/i26�ovE�:�7af<vz <br /> Signature: Date: Aej e.? .ZoiD <br /> EHD 22-02-005 Rev 10109 <br />