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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 6QO East Main Street,Stockton,CA 95202-3029 <br /> Talephone:4209)-46&34XFAX- (249)-468-3433 Web:www sicov.orclehd_ <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> ,Any MINQ. violations noted in the°Notice to Comply' in the attached inspection Report must be <br /> rirrected within 30 dawn of receipt of this inspection. This certification form must be submittedto the <br /> Environmental Health Department(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 Form, or <br /> disputes to any violations,are to be submitted using thls certification and returned to EHD within 30 d <br /> ays <br /> unless otherwise speed in the Inspection.Report. <br /> Note: All EHD staff time associated with falling to comply by the above noted dates will be <br /> - billed at the current hourly fate. <br /> For this certification to be complete the operator-of the site must include: <br /> • A statement documenting what corrective actions were taken or wilt 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 /> inspection Date: o Igo inspected By: i�o.� ewe <br /> I <br /> Facility Address Z�zs �tib, EPAWS: c a <br /> ST�kfu. c,c <br /> I certify under penalty of law that: <br /> 1 I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personalty 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 /> Name: <br /> Title: <br /> Signature: <br /> EW 22-02-005 Rei.I OM <br />