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SAN JOAQUIN COUNTY -� ✓ : r r <br /> ENVIRONMENTAL HEALTH DEPARTMENT � '� <br /> 600 East Main Street, Stockton, CA 95202-3029 �.� _-, <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.si4ov.org/ehd <br /> APR 18 201G <br /> RETURN TO COMPLIANCE CERTIFICATIO1T' <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 (EHD) address at the top of this form within 30 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 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 will be <br /> billed at the current hourly rate. <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 sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> i <br /> Inspection Date: 03 -,5 Inspected By: TJ10 -rVh-(\) <br /> Facility Address: �\M Mkio STT-E;F.T EPA IDW <br /> r1:jkc`f, CA 9 5 13 1 <br /> IIcertify under penalty of law that: <br /> L 1. 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 /> Photos v-' Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Resoondent, <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: Ji CH A- Title: M 2121a - <br /> Signature: <br /> a/1.6 Date: 1 -I <br /> EHD 22-02-006 Rev 10109 <br />