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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Wob;www-§jgqv.gLr eIj <br /> 0 12 <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the Notice to Cornpiyn in the attached Inspection Report must be <br /> carr eded within IQs of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department(EHO)address at the top of this form within 30 days of receipt of the <br /> Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections too <br /> her vi x" noted in the attached Inspection Report(IR)or Continuation Form,or <br /> disputes to any via 4 ations 'be submitted using this certification and returned to EHO within 30 days <br /> , <br /> unless otherwise specified in ft lnsp�dion Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification to be complete the operator of the site must include: <br /> A statement documenting what corrective ions were taken or will be taken for each violation <br /> Copies of sample result imanifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> Operator's certification <br /> Inspection Date. LVA ALI ''>t Inspected By:_ tv) - N AA CU <br /> Facility Address, 1 't �WTtr-A EPA ID#:. <br /> 3 <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 signiftent penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: <br /> Signature, Date: <br /> FH1)22-02-005 Rev 09111 <br />