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002454 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Tefeptione:(209)466-3420 Fax:(209)466-3433 Web:www.sjcov.orc/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 30 days of receipt of the i <br /> Inspection Report. <br /> I <br /> All corrections to other violations noted In the attached Inspection Report(IR)or Continuation Form, or j <br /> disputes 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 <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 will be taken for each violation <br /> • Copies of sample results/manifests/training recordslother appropriate paperwork,andlor photos <br /> verifying corrections <br /> • Operator's certification y <br /> Inspection Date:_/C II)br Inspected By: 4.'i< <br /> Facility Address: I I I I E.KALX% b"k EPA ID#: <br /> 1 certify 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. 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the.informatlon 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: pt� <br /> ^ Title: ��'1I-f C'"�� <br /> Signature: cam- Date JD <br /> EHD 22.02.005 Rev 08108 <br />