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SAN JOAQUIN COUN"rY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:wwwsj ov,oeg/ehd. <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 days of 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 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to other violations 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. <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be hilled at <br /> the current hourly rate ($122). <br /> For this certification t0 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 results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> inspection Date: '�la`f o Inspected B : "�,4 L(-\/ <br /> P P Yr <br /> Facility Address: $S E. i-00i s E AVC . 4-ni PEPA ID#: C A L Goo .2-,2 S B o 5-- <br /> 1 <br /> 1 certify under penalty of law that: <br /> 1. i have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and 1 believe the information to be true, accurate, and complete: <br /> Photos X Paperwork X Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Narne: R t C.t-t A-2 a SS r Title: GNB/t 2aJ M F_N i-4L <br /> GOMPLI i-nICG $PCC,1A r.1 C r <br /> Signature: - Date: Ste° . z4, "ro <br /> EHD 22-02-005 Rev 08/10 <br />