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SAN.JOAQUIN COUNTY <br /> TA-c,I`IEA,CTFrDEPXRT M Een <br /> 600 E=ast Main Street, Stockton, CA 95202-3029 <br /> Telep`ione: (209) 468-3420 Fax: (209)468-3433 Web:www.si4oy.org/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to Comply" in-the attached Inspection Report rn�Ist ba. . ;:;, <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 tl�e, <br /> Inspection Report. <br /> All corrections to other violations rioted in the attached Inspection Report (IR).or-Continuation-_Form,.or .. <br /> disputes to any violations, are to be submitted using this certification and retu.rnecf 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 v►►�Il.be;;.,;.::.::: . .; <br /> billed at the current hourly rate. <br /> For this certification t0 be Complete the operator of the:site must ineiude:° <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,.an.d/or.phot os:-• :. <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date,_ /`� e� Inspected By: <br /> ; <br /> Facility-Address: �`o� ,l�//r � EPA.ID4: <br /> I certify under penalty of law that: <br /> 1. 1 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 /> Photos ��)_Paperwork Statement <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 26191) <br /> Name: Title:_ <br /> Signature: Date: <br /> t00 'd 80109SHOZ I 'm XU SS21 KA QOOH Yid 85 :ZO NOW/600Z/ZO/M <br />