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0 SAN JOAQUIN COUNTV • ENVIRONMENTAL IIEALTH DEPARTMENT 600 Gast Main Strcet,Stockton,CA 95202-3029 Telephone. (209)46$-.3420 Fax. (209)469-34.33 Web.-www.sjgov.org/ehd RETURN TO COMPLIANCE CERTIFICATION Any MINOR violations noted in the"Notice to Comply" in the attached inspection report must be corrected within 30 days of receipt of this inspection. This certification form must be submitted to the Environmental Health Department (END) address at the top of this form within 35 days of receipt of the inspection report. All corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any violations, are to be submitted using this certification and returned to HHD within 60 days unless otherwise specified in the [R. For this certification t0 be Comp ete the operator of the site must include: • A statement documenting what corrective actions were taken or will betaken for each violation • Copies of sample resuit5hnanifi isltraining records/other appropriate paperwork, and/or photos veri fving corrections • Operator's certification Inspection Date: ' ' ___-- _--..._r. Inspected By: !"`(.�w Facility Address:,X02® E.r?�i try s164,h► FPA ID#: G•H" 9:r0sep i certify under penalty of law that: 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. 2. 1 have personally examined the following documentation submitted as proof(if compliance FOR F.ACll VIOLATION and I believe the information to be true, accurate, and acmplete: Photos ---Paperwork Statement .1. 1 am authorized to submit this certification on behalf of the Respondent. 4. 1 ant aware that there are significant penalties for submitting false intonnation. including the possibility ol'a tine and/or imprisonment for known violations. (HSC 25191) Name:. - - Title:-_ Signature Date: ley et --- EHD 22-02-005 Rev 05/07