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11/13/2013 16:18 FAX 209 334 5022 FTG CONSTRUCTION Z003 <br /> SAN JOAQUIIN CO'UN'T <br /> EN'VIRONML•NTAL HEALT14 DEPARTMZNT <br /> 600 East Main Street, Stockton.CA 95202-3029 <br /> Telephone:(1209)450-3 20,Fax: (209)468-3433 Web: www.siray.orL.end <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 (F-HD) 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 EHO within 60 dans <br /> unless otherwise specified in the IR. <br /> For r S certification t0 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: [m tA a �� <br /> Q �Faczlity Address: C <br /> I certify under penalty of law that: <br /> I_ I 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 /> T Photos ✓ Paperwork _Statement <br /> 3. I 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 L <br /> Signature: <br />