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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL IlLkL.TH DEPARTMENT <br /> 600 Easl Main Strcct,Stockton,CA 95202-3029 <br /> Tdephaxe.(209)468-3420 Fay(209)468-3433 Welt:www.-,iQov.orrlehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MLNOR viol 'ons noted in the"Notice to Comply"in the attached Inspection Report must be <br /> corrected within 3 'dan of receipt of this inspection. This certification form must be submitted to the <br /> Environmental He�lth Department(EHD) address at the top of this form within 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to o other violations noted in the attached Inspection Report(IR) or Continuation Form,or <br /> disputes to any via ations, 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 s I ff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourt rate($98). <br /> For this 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 $ample results/manifests/training records/other appropriate paperwork,and/or photos <br /> verifying orreetions <br /> • Operator' certification <br /> I <br /> Inspection Date Inspected Byc�� <br /> Facility Addres : (,,� _ i Com- EPA ID#: <br /> I certify and penalty of law that: <br /> 1. I have co ected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have per onally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIbLATION and I believe the information to be true, accurate, and complete: <br /> i <br /> I <br /> Photos _Paperwork Statement <br /> 3. lam authorized to submit this certification on behalf of the Respondent. <br /> 4. lam 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 /> Narne:sl j h d 11 Ed. a✓d-1 _Title: EXt.ru...sn n".4.0 ComL 11c' <br /> Signature: � �d� Date: (_1A7 <br /> B d elb :Lo ao 6Z Rew <br />