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San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:\,rww.siaov.orq/ehd <br /> RETURN TO COMPLIANCE CERTIF'ICAT'ION <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection_ This certification form must be submitted to the Environmental Health Department(EHD) address <br /> at the top of this form within3D days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other violations noted in the attached Inspection Report(IR) or Continuation Form, or disputes to any <br /> violations, are to be submitted using this certification and returned to EHDwithin 30 days unless otherwise specified in the <br /> Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with tailing to comply by the above noted dates will be <br /> billed at the current Dourly 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 verifying <br /> corrections <br /> Inspection Date: _ ;-9 <br /> I::r�-re,',-�;:;�;1� �1{., Inspected By: <br /> Facility Address: Li_juI 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 inspection date. <br /> 2_ 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information too be true, accurate, and complete: <br /> r0 Photos LO 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 possibility of a fine <br /> and/or imprisonment for known violations. (HSC 25191) <br /> I <br /> Name: Mc,r'`k ` _ <f0 c Title. 641114 <br /> Signature: _ ., , > Date: a'j7 f�f <br /> - L � <br /> JAN 2 6 2U i <br />