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f <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT RE- <br /> �1868 East Hazelton Avenue, Stockton, California 95205-6232t:/ <br /> �� <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.s*gov.org/ehd <br /> ENV/RoovME <br /> RETURN TO COMPLIANCE CERTIFICATIONRA4'Ti,q E�� ' <br /> Any MINOR violations not d in the "Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 days ofi 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. HSC 25404.1.2(c)(1) <br /> All corrections to other vio ations 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 within 30 days <br /> unless otherwise specified in the Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates 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 res Its/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: C Inspected By: .SfON PAVU0— <br /> Facility Address: Dr WCVt �(41WEPA ID#: CAL C <br /> I certify under penalty of law that: <br /> 1. 1 have corrected tl�e violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally xamined 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 th�re are significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: �l�t 121 tet'cl • �1,7a.� � Title: O(Aj L-2 P <br /> Signature: Date: EV v <br /> ------�� <br /> EHD 22-02-005 Rev 04/19/12 <br />