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. AN' <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202.3029 <br /> Telephone:(209)468-3420 Fox:(209)468.3433 Web:www.sittoy.or&hdhd <br /> I <br /> I <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 furm 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(IR) or Continuation Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD within 3-0 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:_ 2 ' 3 C� `� Inspected By: <br /> Facility Address: I Ul;'ou w, 1 12er4 F PO , BPA ID#: <br /> [11 n rr7C-C P t <br /> I certify under penalty of law.that: ._ <br /> 1. 1 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. 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: �f2 /1y Title: <br /> 77 <br /> Signature: Date: <br /> f <br /> EHD 22-02-005 Rev 11/07 <br /> T00ln QUOdNSFJdGHHZFI OL896CZ60Z %Vd Z2:ST L00Z/8T/ZT <br />