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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telep.%ortj: (209) 468-3420 Fax: (209) 468-3433 Web: www.s*qov.or-q/ehd <br />NETURN 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 <br />Environmental Health Department (EHD) address at the,top of this form within 30 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 withini6days <br />unless otherwise specified in the Inspection Report. <br />Note: All EHD staff time associated with faiilli�g.to comply by the above noted dates will be <br />billed at the current hourly rate. <br />I I i <br />For this certification to be completethe operator of the site must include: <br />*'A statement documenting what corrective actions were taken or will be taken for each violation <br />o Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />Inspection Date: <br />Inspected By: <br />Facility Address: I EPA IDa <br />FTMM <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection clat <br />E. I 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 />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 />Ez= <br />EHD 22-02-005 Rev 08/08 <br />"M <br />