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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 •v/q �� <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sig v. r e A�Y� ZQJS <br /> ices `Ty <br /> RETURN TO COMPLIANCE CERTIFI ATION <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 receipt of the <br /> Inspection Report. <br /> All corrections to other violations noted in the attached Inspection Report(' )or Continuation Form,or <br /> disputes to any violations, are to be submitted using this certification and reti imed 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 billed at <br /> the current hourly rate ($122). <br /> For t111S 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 appropriatt paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification / 1 <br /> Inspection Date: � / Inspected By: 12-;r!e W m1 <br /> �J <br /> Facility Address: 22 N �t/CEPA ID#: L 7�10 -7y1 <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report froi n the above-mentioned <br /> inspection date. <br /> 2. I have personally examined the following documentation submitte proof <br /> of compliance FOR <br /> EACH VIOLATION and I believe t=Paperwork <br /> ion to be true, ac ate,and complete: <br /> Photos Stat ment <br /> 3. I am authorized to submit this certification on behalf of the Respond nt. <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. (HS 25191) <br /> Name: �oe -1 � Q Q ��j p l/} Title: 5 244 /" tm <br /> Signature: Date: 0 OI 5 <br /> EHD 22-02-005 Rev 08/10 <br />