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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.. siaov.or 1' " <br />E C E I VE a`...) <br />� <br />RETURN TO COMPLIANCE CERTIFICATIQy,4 ��� 0 6 2J14 <br />. <br />` 1VIRONMENTAL <br />"C?,'_?'H ,DEI)P RTMENT <br />Any MINOR vi lations n ted in the "Notice to Comply" in the attached Inspection Report must be <br />corrected withi 30 da s;of receipt of this inspection. This certification form must be submitted to the <br />Environmental ealth Department (EHD) address at the top of this form within 30 days of receipt of the <br />Inspection Re rt. <br />All corrections'o other v lations 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 30 days <br />unless otherwi e specifi4d in the Inspection Report. <br />Note: All EH staff ti.e associated with failing to comply by the above noted dates will be <br />billed t the cu rent hourly rate. <br />For this martificat,ion to be complete the operator of the site must include: <br />• A stateme it docum"ming what corrective actions were taken or will be taken for each violation <br />• Copies of ample re6ults/manifests/training records/other appropriate paperwork, and/or photos <br />verifying c rrections <br />_• Operator's certificatioii <br />Inspection D te: Inspected By: <br />Facility Address: !aC EPA ID#: <br />I certify uncer penalty of law that: <br />1. I have corrected violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />2. 1 haversonallyle amined the following documentation submitted as proof of compliance FOR <br />EACH IOLATIO S4 nd I believe the information to be true, accurate, and complete: <br />Photos y PaperworkStatement <br />3. 1 am aut1`orized t4 submit this certification on behalf of the Respondent. <br />4. 1 am afire that thele are significant penalties for submitting false information, including the <br />possibili y of a fine gond/or imprisonment for known violations. (HSC 25191) <br />Nam& <br />EHD 22-02-005 Rev <br />Title: <br />Date: /--L, - <br />