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SAN JOAQUIN COUNTY 1it <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.or-q/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 the attached Inspection Report (IR) or Continuation Form, or <br />d s utes to aw violations, are to be submitted usin this certifiaa-t.o <br />a - 0 INIZ1111, <br />Note: All 1EHI) 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 completethe 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 />* 1 0 . - <br />Inspected By: <br />12 ! 111 11 111 1 <br />11 111 77f! 1 111 1111 1 11!! 1 iiiiiiiiijil ?1I 111 111111 NO 111!11 1 111 <br />site <br />1191L�;,jk <br />:F—ffsl ' ILYA 1011111 LOU, IM IILIPK%ojl 1� <br />Photos Paperwork Statement <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: Title: <br />Signature: Date: <br />EHD 22-02-005 Rev 10/09 <br />