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SAN JOAQUtN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E38t Main Street,Stockton,CA 95202-3029 <br /> Telephone.(209)468-3420 Fax(209)468-3433 Web.www.,,i20v.01r/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR viol tions 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 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 viations, are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise s ecified in the Inspection Report. <br /> Note: All EHD s ff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate <br /> For this certification to be complete the operator of the site most include: <br /> • A statement documenting what corrective actions were taken or will betaken for each violation <br /> • Copies of ilample results/manifests/training records/other appropriate paperwork,and/or photos <br /> verifyingorrections <br /> • Operator' certification <br /> / (� <br /> Inspection Date _ 50`1?��`� Inspected By � � \.t.t <br /> �y L4 <br /> Facility Addres : , Cit-- EPA ID#: <br /> I certify under penalty of law that: <br /> 1. I 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 VI13LATION and I believe the information to be true, accurate,and complete: <br /> Photos _Paperwork Statement <br /> 3. lam authorized to submit this certification on behalf of the Respondent. <br /> 4. I am awar that there are significant penalties for submitting false information,including the <br /> possibilit of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Q _ <br /> Name: h ✓d� Title: �m <br /> Signature: � d� Date: Q7� <br /> B -d eib :LO 80 6Z ReW <br />