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SAN JOAQUIN COUNTY 3NVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 Tele hone: (209)468-3420 Fax:(209)468-3433 Web:www. -sjgoy.org/ehd RET RN TO COMPLIANCE CERTIFICATION Any MINOR violations n ted in the"Notice to Comply"in the attached Inspection Report must be corrected within 30 days f receipt of this inspection. This certification form must be submitted to the Environmental Health De artment(EHD) address at the top of this form within 35 days of receipt of the Inspection Report. All corrections to other vi lations noted in the attached Inspection Report(IR) or Continuation Form, or disputes to any violations, e to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the Inspection Report. Note: All EHD staff tim associated with failing to comply by the above noted dates will be billed at the current hourly rate ( 105). For this certificati n to be complete the operator of the site must include: • A statement docu enting what corrective actions were taken or will be taken for each violation • Copies of sample r sults/manifests/training records/other appropriate paperwork,and/or photos verifying correctio s • Operator's certific tion Inspection Date: � Inspected By: e Facility Address: 4 EPA ID#: (fa �2(0j I certify under penalty f law that: 1 I have corrected th violations specified in the Inspection Report from the above-mentioned inspection date. 2. I 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_ I am authorized to submit this certification on behalf of the Respondent. 4. I am aware that ther are significant penalties for submitting false information, including the possibility of a fine nd/or imprisonment for known violations. (HSC 25191) Name: Title: Signature: Date: EHD 22-02-005 Rev 11/07 J