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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> I elephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/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 <br /> Inspection Report. <br /> All corrections to other violations noted in thr 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 compiy by the above noted dates will be <br /> [pilled at the current hourly rate. <br /> For this certificati®n t® 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 /> I <br /> Insper-flora Date=: Tim I , I/V � inspected By. <br /> e �, �2 <br /> Eacilrty Address: % ` EPA A 04: GNA 0 <br /> l , VIAi <br /> 1 certify under penalty of law that: <br /> . 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 /> Photo Paperwork Statement <br /> 3. 1 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 /> j possibility of a fine and/or imprisonment for known violations. (HSC 25 i g i) <br /> i`�Ic.IT��; �-G;y^Se it <br /> iie: o L <br /> irr all l e. <br /> can r.•m_nn�Roy±rnma <br />