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q vjav„ <br />San Joaquin County ,Loq q S 3 _-6qq <br />Environmental Health Department <br />1868 East Hazelton Avenue, Stockton, Cepfomia95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 4683433 Web: www.sioov.org/ehd <br />RETURN TO COMPLIANCE CaRTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br />receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD) address . <br />the top of this form within 30 days of receipt of the 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 disputes to any <br />violations, are to be submitted using this certification and returned to EHDwithir 30 days unless otherwise specified in the <br />Inspection Report. HSC 25185(c)(3) <br />Note: All EHD staff time associated with failings to corrinGy 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 1,011 be taken for each violation <br />Copies of sample results/manifests/training recordsrothar appropriate paperwork, and/or photos verifying correction: <br />Inspection Date: <br />Facility Address: <br />I certify under penalty of law that: <br />Inspected By: <br />-m <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIC <br />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. lam aware that there are significant penalties for submitting false information.. including the possibility of a fine <br />imnrisonment for known violations. (HSC 25191) <br />Title: A/C.— <br />Date: eel-, ^ <br />T'C2rn tt \DCa'• Co¢4-PC'ce¢� � UQL6R0@U 'TD C�0.S. <br />ZrtRrn ,i �0� �u�r,� 404ta�lLo t �e 'v.0. V_ours �U Vi-ave2tr1 LoC� Ate PLOW! <br />oMa YVt��2 SVS'-C'1iZ�� 1.12SL2 'R-QC"POs�OQ'D -fiD Co,2RP�'r.K. Q�S'UrTH2. b.n. <br />�,- <br />TR�e 2 �l PDMS`7 <br />LOA,�3_'j , n� D.c�. (>�t a\sc� <br />k__W'P C�-To rnonTlk� ( \Y�C4e�od�s'- <br />S`Q+M 1F3blo } CDSZ4QCT217 0�AT `TtMC p� 1(1SPeCCIOI�. PLL <br />3a°t (\/ (,ee=-2 i_0c,Cyea bre 1n5ve�-rt� �� �tzw `� RS gee<\( <br />I <br />s4 moi C 04-4-e C-qe:D . <br />