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{ <br /> a <br /> f <br /> SAN JOAQUIN COUNTY, <br /> ENviRoNMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www:si og v_org/ehd <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 35 days'of receipt of the <br /> Inspection Report. <br /> All corrections to other violations noted in the attached Inspection Report 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 billed at <br /> the current hourly rate($125). <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/manifegWtraining recordslother appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> y i3 <br /> Inspection Date: % Inspected By: ujr TRA•V,If <br /> hs <br /> Facility Address: f�AIA1 YF EPA ID#: <br /> N►�-�✓��'�� 9s33�- <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I 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 I/ Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. I am aware that there are significant penalties for submitting false information, including the <br /> possibilitk of'a fine and/or imprisonment for known violations. (HSC 25191)' <br /> Name: gea ilo L1 l T9,AAWitle: ' <br /> Signature: Date: <br /> EHD 22-02-005 Rev 10-07 <br />