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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 SEP 3 0 cola <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.si4Dv. �IVIVILN{ HEALTH <br /> ___ PERMIT/SFRVI.rFS <br /> RETURN TO COMPLIANCE CERTIFICATION <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 /> Inspection Date: C� ; 1u�ICS Inspected By: <br /> 4�ic'n"iCCa ( s"c�OC ��C7 �4 <br /> Facility Address: IU-61 � j �f CSP 111P t , EPA ID#: <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 y 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 25191) <br /> Title: f om'i <br /> V ` <br /> Date: Q i 1D <br /> Signature,, tl• --- — <br /> EHD 22.02-005 Rev 10109 <br />