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• SAN JOAQuuv COUNTY ENVMDNA{ENTAL HEALTH DEPARTMENT 604 E. Main St, Stockton, CA 95202.3029 Telephone: (209) 468.3424 Far: (209) 466-3433 Web: wWW.sjgov.ortF)chd RETURN TO COMPLIANCE CERTMCATION Any MLL violations noted in the "Notice to Comply" in the attached Inspection Report must be tett within 30 days of receipt of this inspection. This certification form must be submitted to tate Environmental l-lealth Department (EHL)) address at the top of this form within 35 days of receipt of the Inspection Report. All cot Monts to other violations noted in the attacbed Inspection Report or Continuation Form, or disputes W any violations, are to be submitted usirtg this certification and returned to EHD within 30 days unless otherwise specified in the Inspection Report, Note. All CHD stair time associated with faiUng to comply by the above noted dates will be billed at the current hourly rate ($12 For this certification to be complete the operator of the site must include: A statement documenting what corrective actions were taken or will be taken for each violation Copies of sample resultshnattifests/training records/other appropriate paperwork, and/or photos verifying corrections 0 Operator's certification Inspection Date: i Inspected By: Facility Address: -t%'. V14 VI --It) Rd I certify under penalty of law that: EPA": 1. I have corrected the violations specified in the Inspection Report from the above-rneniioned inspection date. 2. I have personally examined the following docs nentation submitted as proof of compliance FOR EACH VIOLAT ON and I believe the information to be true, accurate, and complete: _x--1°hotos Paperwork Statement . 3. I am authorized to submit this certification on behalf of the Respondent. 4. I am aware that there are significant penalties for submitting false information, including the possibility of a fire and/or imprisonment for known violations. (HSC 25191) Name. -1� t l Si EHD 22-02-005 Reiff 08110 Date:j1-