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. SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 E C E I �{'E D Telephone:(209)468-3420 Fax:(209)468-3433 Web: eb:ws ww ' ov.or � RETURN TO COMPLIANCE CERTMCAW*NMENTALHEALTH PERMIT/SERVICES 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(EHD)address at the top of this form within 35 days of receipt of the Inspection Report. Allcorrectionsto other violations noted in the attached Inspection Report(IR)or Continuation Form,or disputes to any violations,aze to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the Inspection Report. Note: All EIlD staff time associated with failing to comply by the above noted dates will be billed at I he current hourly rate($122). Finclude: • A statement documenting what correcrive actions were taken or will be taken for each violation • CoQies of sample results/manifests/training records/other appropriate paperwork and/or photos Vert corrections • Operator's certification Inspection Date: Inspected InspectedBy:�� \� fi`� FacilityAddress:�a '?_-,\, � \A10- r_,�^j EPAID#: I certify under penalty of law that: 1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. 2. I have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and I believe the information to be true,accurate,and complete: Photos Paperwork Statement 3. I am authorized to submit this certification on behalf of the Respondent. 4. I am aware az significant penalties for submitting false information,including the possibilitn r imprisonment for known violations. (HSC 25191) Name: Title: CEb Signature: S-f?Z-V9 aromp Date: {�I3a I)b EHD 22-02-005 Rev 08/10