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SAN JOAQUIN COUNTV <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,Yd Floor,Stockton,CA 95202-2708 <br /> Telephone;(209)468-3420 Fax. (209)468-3433 Web:ww,W.sjgov.orW <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 iform must be submitted to the <br /> Environmental Health Department(EKD) 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 Repot(IR) or Continuation Form,or <br /> disputes to any violations, are to be submitted using this certification and returned to BHD within 60 days <br /> unless otherwise,specified in the JR. <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, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: � _CL —0-1 Inspected I by: -1.6 <br /> Facility Address: 2A 1"I Os EPA ID#:1 C ikb q J62, 33 6 31 4K <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. DISC 25191) <br /> Name:_ _N161 <br /> Date: ;,n -o-I <br /> EHD 22-02-005 Rev 12-04 <br /> Z00/Z001A 13SK018 VLL899V80Z XVj LZ:OL LOOZILZIVO <br />