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SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.o /ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <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 30 days of receipt of the <br /> Inspection Report. HSC 25404.1.2(c)(1) <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 this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD 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 will be taken for each violation <br /> • Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification i <br /> Inspe:Address: <br /> ate: I I I b l Inspected By: jRU1 ) <br /> Facilitk20 IA1 V0CPHiZE AUEEPA ID#: <br /> 11P,11TE-C(a/ CI cnder penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> on <br /> f of <br /> 2. 1 have personally <br /> EACH VIOLATION and examined bel eve the formation tong be true, accurate Sand compleepliance FOR <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: © w ?• <br /> Signature: <br /> Date: c 11 <br /> >tir tU +uI� UST +44)6 Rk ebb % f v mate L' <br /> Cm�wee d�lei i n e"Jl" A-V <br /> EHD 22-02-005 Rev 04/19/12 i � U40-0 ha�PC <br /> �A.0 alca& V 'Y1 <br />