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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: wv«v.s1 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 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 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 gate. <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 betaken 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:_) T Inspected By: <br />—L.4 <br />Facility Address:,2(�5� _S T EPA ID#: <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. 1 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 fine and/or imprisonment for known violations. (HSC 25191) <br />Name: S'LW14WIA'�) ))Ffl Title: <br />Signature: Date: <br />EHD 22-02-005 Rev 11/07 <br />Ow' <br />(t /()//,v <br />T -d 8bSTbS66024 ^� -� uolTTgp uiquew dST:To 80 60 ADW <br />