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MAY d 3 i;`6110 <br /> •. <br /> a :.. SAN JOAQUIN COUNTY <br /> F�+t1l1RChWJMEN7AL HEAL-ri DEPARTI°vviEW ENV1R(ft1f-NT HEALTH <br /> 600 East Main stn:et. Stockton. CA 95202-3029 PERMIT/SERVICES <br /> Telephone:(209)4683420 Fax:(209)468-3433 Web.www4 _or eM <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply'in the attached Inspection Report must be <br /> f-orracted within 30 days of receipt of this inspection. This certification form most be submitted to the <br /> Environmental Health Departrnent(EHD)address at the top of this form within 30 days of receipt of the <br /> inspection Report. <br /> All corrections to other violations noted in the attached Inspection Report(IR)or Continuation Farm, or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br /> unless othenvise specified in the Inspection Report_ <br /> Note: All END staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly 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 vAll be taken for each violation <br /> * Copies of sample results/manifests/training recordslother appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> F- <br /> I Inspection Date: -3 — g 2� — I Inspected Ey:_'ivy Ai m <br /> Facility Address: 1b oc:- -n) , QA,e,r0 EPA ID#: CAL an en <br /> �5 g R g <br /> I certify under penalty of law that: <br /> have corrected the violations specified in the inspection Report from the above-mentioned <br /> inspection date. <br /> E <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: 1 <br /> fPhotos____A_Paperwork Statement <br /> 3. ! am a,sthorized to submit this certification on behalf of the Resident. <br /> 4. 1 am aware that there are significant penalties for submitting false information including the <br /> possibility of a fine and/or imp nment for known violations. (HSC 251i' ) <br /> J <br /> lx Name: i� - Tide: <br /> J� Signature: ,'`� Date: r 1 <br /> _..._._ <br />