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0 <br /> 002454 <br /> SAN JOAQUIN COUNTY <br /> EWARONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3OZ9 <br /> Tefep.'ione:(209)468-3420 Fav(209)488-3433 Web.,www.siaov.orgLohd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be <br /> coMNtgo Wt <br /> �tftiri�3a 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 /> AN 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 Wftbi�ys <br /> unless otherwise specified in the Inspection Report, <br /> Note: All EHD staff time associated with failing to comply by the above noted date$will be <br /> billed at the current hourly rate. <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 paperwork, andlor photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: Inspected By: AVi-C -ACaID'i <br /> Facility Address: lb"t EPA ID#:_C.AL. <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 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- <br /> (j- <br /> �A <br /> Signature- Date <br /> EHD 22-02-005 ROY 98109 <br />