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SAN JOAQUIN COUNTX <br /> ENVIRONMENTAL HEALTH DFPARTytENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Tel hone:(209)468-3420 Fax:(209)468-3433 Web:www.si ov.o eke(( <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations n. ted in the"Notice to Comply" in the attached inspection ro-port must be <br /> corrected within 30 days f receipt of this inspection. This certification form must b.;sub�r fitted to the <br /> Environmental Health De artment(EHD) address at the top of this form within 3.5 drys of ,eceipt of the <br /> inspection report. <br /> All corrections to other violations noted in the attached Inspection Report([R) or Coiitinuaiion Form, or <br /> disputes to any violations, are to be submitted using this certification and returned to EHD ,vithin 60 days <br /> unless otherwise specified in the IR. <br /> For this cel;tificati n t0 be COMPIete the operator of the site must ir);hide: <br /> o A statement docu eating what corrective actions were taken or will be taker for e2 ch violation <br /> e Copies of Sample sults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying correctio s <br /> Operator's certifie tion. <br /> Y- Gr <br /> X51/ <br /> Inspection Date: ' Inspected 19Y. ("I <br /> - <br /> Facility Address: C EPA. ID#: (',a9'17 7'� f1� _ <br /> CA;, c-)S-� <br /> Nj-oeftify under penalty flaw that: <br /> 1. I have corrected th violations specified in the Inspection Report from the above-momtioned <br /> —'inspection date. <br /> 2r iayco5 rsonally e amined the following documentation submitted as proof of compliance FOR <br /> - �tCH VIOLATION and I believe the information to be true, accurate, and cmiplcie: <br /> Photos ,Eapcn v.@Tk Stakemen� <br /> #�k3. I am authorized to s�bmit this certification on behalf of the Respondent. <br /> 4. 1 am aware that tlierl are significant penalties for submitting false information, including the <br /> possibility of a fine�nd/or imprisonment for known violations. (HSC, 25191) <br /> Narne: ( l ! � Title: <br /> Signature: G� ►'�} ^ i CDate: <br /> PPP ��-n7_nnc no. nsim <br />