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• SAN JOAO UIN COUNTY • <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3f° Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.ore/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 35 days of�eceipt 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 60 days <br />unless otherwise specified in the 1R. <br />For this certification t0 be COI7lplete 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: -:5 &R 0-1 <br />( Ii &b vn((_L�c:� <br />Facility Address::5a v, d, Ca rv\.n C At- <br />t:j S a3 1 <br />I certify under penalty of law that: <br />Inspected By: Socqiv /t�mlez <br />EPA I'D#:_C A L_ 0 t2O R 5 j !?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 Y._Statement <br />3. lam authorized to submit this certification on behalf of the Respondent. <br />4. I 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 2519 1) <br />Name: _;o 461,z(Po1_ Title: FAC;A <br />Date: <br />FTM 22-02-01)1 Rev 17.-04 <br />60 39Vd d9I 999868660ZT PT:11 L00Z/ZZ/90 <br />