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• <br /> 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:www.sigov.org/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any OR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br /> correc ed within 30 days of receipt of this inspection. This certification form must be submitted to the <br /> Envirc nmental Health Department(EHD) address at the top of this form within 30 days of receipt of the <br /> Inspe ion Report. <br /> All C01 Tections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br /> disput s 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. <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. <br /> For this certification t0 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 /> • <br /> Operator's certification <br /> Inspection Date: Jr /9 2�q n ' Inspected By: RE 0 <br /> Facility Address: q rf Rom EPA ID#: CA k= 05D (51,'1 r7(o <br /> I ertify under penalty of law that: <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 aperwork 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 2519 1) <br /> me: V Title: ' )< <br /> S gnature: Date: SRI2U'O 9 <br /> EHD 2-02-005 Rev 08/08 <br />