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AN JOAQUIN COUNTY <br /> ENvIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax. (209)468-3433 Web:wWw.sigov.orf_r/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any hjnjOR violations noted in the"Notice to Comply"int e attached inspection report must be <br /> corrected wit in 30 days of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department (EHD) address at the top oft is 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 60 days <br /> less otherwise specified in the IR. <br /> certificationFor this 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 ate: Inspected By- <br /> Facility res : EPA ID#: <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> . 1 have personally examined 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. I am authorized to submit this certification on behalf of the Respondent. <br /> . I am aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine and/or iriso et for known violations. (HSC 25191) <br /> Name: Title: <br /> Signature: ate: <br /> EHD 22-02-005 Rev 05/07 <br />