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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):46$-3433 Web-wMW.Sgay-org/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MLNL R violations noted in the "Notice to Comply" in the attached Inspection Report must be <br /> rrected ithin 30 da s 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(1R) or Continuation Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD wit in 0 d s <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 t4 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 /> O era#or's certcation <br /> Inspection Date: Inspected B : �1 <br /> /2 3 y R <br /> Facility Address:,2 cy`-�7 So- &S _7,u b> EPA IDMA2A4�ZoQr - <br /> tPW t Cll) <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specked 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--K—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 /> Name: f <br /> � �- Title: ,r2/C L <br /> Signature: ?10) Date: <br /> t-WD 22.02.005 Rev 08/08 <br />