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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:www.sjgov.org/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to Comply"'in the attached-Inspection-Report must be' f <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 /> .-W.. - <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 wiil 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 records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> -' • Operator's certification <br /> Inspection Date: Inspected By: <br /> Facility Address: r s , „ r o_ '�. EPA Ib#: r _ <br /> I 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., 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 /> f Photos E} Paperwork Statement 4 - <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: Title: <br /> Signature: Date: <br /> EHD 22;02-005 Rev 08/08 <br />