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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)468-3433 Web:w .sicov.orc/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 /> 'I 1spectioniRepGd.- <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 ($105 : <br /> Forthiscertification to 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 records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: "7-Z2 —y5 Inspected By: 110AI /,O ' <br /> Facllity Address: 2-7 ~5/ V54 oO9 EPA ID#: GGI✓ �� 3�� <br /> I certify under penalty of law that: <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 informatign to be true,accurate, and complete: <br /> X__�Plhotos Paperwork Statement <br /> 3. I 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 and/or imprisonment for known violations. (HSC 25191) <br /> Name: e2 J2 2/O �� �'�Z Title: 4A_ <br /> Signature: Date: . �Z O <br /> . .... . ....__ ... .. ............. <br /> EHD 2M2*0 Rev 08;08 ' <br />