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SAN JOAQUIN COUNTY ;" <br /> ENVIRONMENTAL HEALTH DEPARTMENT `S a-�s <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telep one: (209)468-3420 Fax: (209)468-3433 Web:www.siQov.orp/eh& <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations no ed in the "Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 days f receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health De artment (EHD) address at the top of this form within 30 days of receipt of the <br /> Inspection Report. HSC 5404.1.2(c)(1) <br /> All corrections to other vi lations 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 specifie in the Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff ti a associated with failing to comply by the above noted dates will be <br /> billed at the cur ent hourly rate. <br /> For this certific tion to be complete the operator of the site must include: <br /> • A statement docume ting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample re ults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certificatic n <br /> Inspection Date: 2-- Inspected By:Stacy Rivera <br /> Facility Address: . - EPA ID#: ( ( ,D(�(1-34( (LQ <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 authorizeI <br /> mit this certification on behalf of the Respondent. <br /> 4. 1 am aware thaare significant penalties for submitting false information, including the <br /> possibility of a /or imprisonment for known violations. (HSC 25191) <br /> Name:hAU )p fJ�t�� Title: ~ 0 V3- <br /> Signature: Date: Z <br /> EHD 22-02-005 Rev 09/11 <br />