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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) 468-3433 Web: www.sigov.or /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 mi.st be submitted to the <br />Environmental Health Department (EHD) address at the top of this form within 5 days of receipt of the <br />Inspection Report. <br />All corrections to other violations noted in the attached Inspection Report (1R) o <br />disputes to any violations, are to be submitted using this certification and retume <br />unless otherwise specified in the Inspection Report. <br />Continuation Form, or <br />to EHD within 30 days <br /> <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 ($122). <br />For this certification to 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 parrwork, and/or photos <br />verifying corrections <br />Operator's certification <br />Inspection Date: 8414 /, 0 <br /> <br />Inspected By: 774 (..cy <br /> <br />Facility Address: 8 5 . c_oui s c qvc . L.4n-ttt0PEPA ID#: C. A L000 .1-.1S (90 <br />I certify under penalty of law that: <br />1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />1 have personally examined the following documentation submitted as p oof of compliance FOR <br />EACH VIOLATION and I believe the information to be true, accurate, nd complete: <br /> Photos X Paperwork X Statem nt <br />1 am authorized to submit this certification on behalf of the Respondent. <br />1 am aware that there are significant penalties for submitting false info ation, including the <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br />Name: c_t-i- Anti) co% Title: et•Nktkoi-J Pier/TA L.- <br />Signature: <br /> <br />comp L., ce sPocoN Li sr <br />Date: ePi. 7-4, 2—o to <br /> <br />EHD 22-02-005 Rev 08/10