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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E.Main St.,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.si¢ov.or /t 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 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to other violations noted in the attached Inspection Report or Continuation Form,or <br /> disputes to any violations, are to be submitted using this certification and retuned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate($98). <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 /> Inspection Date: — R Inspected By: _ <br /> Facility Address: \OY,78 t4ba VAr ql EPA ID#:rA/_C1yi_,n Z9 j oi�9 <br /> I certify under penalty of law that:SCJ. tEl <br /> I:I(Q�L �e3�or 9� J <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally 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. 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 99fine and/or imprisonment for known violations. (HSC 25191) <br /> Name:? Title: <br /> Signature: Date: <br /> EHD 22-02-005 Rev 10-07 <br /> T 'd ££6£896:0l 8299T£6602T NOan3HD U0d60W:WOJd 92:TT eoo2-T£-N0f <br />