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• SAN JOAQUIN COUNTY • RECEIVED <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 MAR 2 1 ZO1Z <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.oM/ehd <br />E.nnenNIII'Mnr HEALTH <br />PERMIT/SER%4CES <br />RETURN TO COMPLIANCE CERTIFICATM r i <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection fZeor must be <br />corrected within 30 days of receipt of this inspection. This certification form must besub I ed to theyp `• <br />Environmental Health Department (EHD) address at the top of this form within 30 days teipt of the 4,�.y .:. <br />Inspection Report. HSC 25404.1.2(c)(1) Cu '' r <br />All corrections to other violations noted In the attached Inspection Report (IR) or Copftuatlonqrm, or # ,; <br />disputes to any violations, are to be submitted using this certification and returned to(EHD n 30 da s <br />unless otherwise specified in the Inspection Report. HSC 25185(c)(3) t3 <br />Note: All EHD staff time associated with failing to comply by the above n%Zd dates will be <br />billed at the current hour) rate. <br />For this certification 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 />Inspection Date: 3- Y I�_ Inspected By: /�m u^w <br />Facility Address: S 5e=" Q- EPA ID#: <br />C/� 111_) <br />I certify under penalty of Iawlthat: <br />W OM71-722 <br />1. 1 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. 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 />Title: l='A5 cam•, fi �) ��c� �y i <br />ZO I Zai %-L <br />EHD 22-02-005 Rev 09111 <br />r <br />