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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 7 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd Ri N RETURN TO COMPLIANCE CERTIFICATION Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report ML St he corrected within 30 days of receipt of this inspection. This certification form must be submi ed to the Environmental Health Department(EHD)address at the top of this form within 30 days of r ceipt of the Inspection Report. All corrections to other violations noted in the attached Inspection Report (IR}or Continuation Form, or disputes to any violations, are to be submitted using this certification and returned to EHD vfithin 30 days unless otherwise specified in the Inspection Report. Note: All EHD staff time associated with failing to comply by the above noted ates will be billed at the current hourly rate. For this certification t0 be Complete the operator of the site must incl de- • A statement documenting what corrective actions were taken or will be taken for each liolation • Copies of sample results/manifests/training records/other appropriate paperwork, and/)r photos verifying corrections • Operator's certification Inspection Date: �'6 0 Inspected By: "�Fg '11 AR Facility Address: 1111 rz.**fQ.sr MrrE A'99-, MMUEPA ID#: I certify under penalty of law that: 1. 1 have corrected the violations specked in the Inspection Report from the above-mentioned inspection date. 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION and I believe the information to be true, accurate,,and complete Photos Paperwork Statement 3. 1 am authorized to submit this certification on behalf of the Respondent. 4. 1 am aware that there are significant penalties for submitting false information, inclu, ing the possibility of a fine and/or imprisonment for known violations. (HSC 25191) Name: 84 114 Title: M69 Signature: Pu& Date: G-- 15--117 EHD 22-02-005 Rev 10109 �5a 3 eavl @5ov-A I i bgd(- + (o, CAY1 c� l 6 a E)'_z( vs6-,