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SANJOAQM COUNTY <br /> ENVIRONMENTAL HEALTH DEPAR'lIv1ENr <br /> 600 East Mainz Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468.3420 Fax:(209)468-3433 Web:vwvw. ' oyoralehd <br /> RETURN TO COMPLIANCE CERTINCATION <br /> Any MINOR violations noted irnthe"Notice to Comply'in the attached Inspection Report must be <br /> corrected within 30 days ofreceipt ofthis inspection. This certification form rnustbe submitted to the <br /> Environmental Health.Department(EHD)address at the top of this form withh 35 days ofreceipt 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 anyviolations,are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified intbe Inspection Report. <br /> Note: All EHD staff time associated with failing to.comply by the above noted date s will be bille d at <br /> the cm-rent hourly nate ($122). <br /> For this certification to be COmplete the operator ofthe site must include: <br /> • A statement documerEting what corrective actions were taken or will betaken for each violation <br /> • Copies of sample resultshmanifests/ g records/other appropriate paperwork,and/or photos <br /> veri6dng corrections <br /> • Operator's certification <br /> Inspection Date: 32,0 13 hispected By �� <br /> Facility Address: J12.0ty •Vlsc. ckw EPA ID#: CAL. S54'Z2A <br /> rVvW-44 44., P, Gds q cr>2A t <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection.Report from the above-mentioned <br /> inspection dame. <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the iaformationto be true,,accurate, and complete: <br /> Photos Paperwork ! Statement <br /> 3. I am authorized to submit this certification on behalf ofthe Respondent. <br /> 4. I am aware that there are significant penalties for subs false information,including the <br /> possibility of a fame andimprisonment for knownviolations. (HS C 2519 1) <br /> Name:, Title: R-14111- ' <br /> Signature: Date: 17--21-243 <br />