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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E.Main St.,Stockton,CA 95202-3029 <br /> Telephone: (209)468-3420!irx:(.209)468-3433 Web:AwK >uv.or chd <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 ($115). <br /> For this Cei'tTfiCat1011 1:0 be C0111pIt'te the operator taken for each violation <br /> • A statement documenting what corrective actions were taken or will be <br /> • Copies of sample results/manifests/training records/other appropriate paperwork, andJor photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspected By: 0,6 nij(A 01fA—; <br /> Inspection Date: t '(� p <br /> EPA ID#: s <br /> Facility Address: <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 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 /> Name: IV ` `CC,41'� ltG C)� _ <br /> Title: 6 ��}, <br /> Date: .... <br /> S i gnature: <br /> EHD 2L_02.005 Rev 1()-07 <br /> — — - -- ------ --..__ <br /> t00[A N11s'I'Ing VDaJN" LTS£6tZ609 XVd Z£:60 OTOZ/ZO/60 <br />