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�s 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:Mq ov.or 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 It <br /> to the <br /> Environmental Health Department(EHD) address at the top of this form within 35 days of receipt of the <br /> inspection report. <br /> All co tions rm <br /> disputes to any violations, are to be submitted using this certification <br /> tions to other violations noted in the attached Inspection Report(IR) or Continuation Fo , or <br /> unless otherwise specified in the IR. and returned to EHD within r6o days <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 <br /> F <br /> Date:_ /oy/s) Inspected By: <br /> dress: />g� U/ n�f ` EPA ID#: edL ooa 367IFOR <br /> certy under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-menti <br /> inspection date. <br /> 2. I have personally examined the following documentation submitted as proof of compli <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete: <br /> Photos `Paperwork Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. I 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: d4V Wj£2 ee*(v£ Title: JU%c,u <br /> Signature: Date: /0 1671- 6? <br /> EHD 22-02-005 Rev 05/07 <br />