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0 002454 x . . <br /> SAN JOAQUIN COUNTYREr <br /> ENVIRONMENTAL HEALTH DEPARTMENT ,„ i <br /> 800 East main Street, Stockton, CA 95202-3029 <br /> Te/ep`®one:(209)48$-3420 Fax:(209)468-3433Web: .siaov.or, ehd MAR <br /> `2 11 <br /> NTY <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 thin 30 days of receipt of the <br /> Inspection Report. <br /> All corrections to other violations noted in the attached Inspection Report (I ) 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 <br /> billed at the current hourly rate. <br /> For this certification t, 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: / ' d t Inspected By:L-La�� <br /> ( <br /> Facilitydress: ( o ,,- � ... i 8 o a+4 <br /> i <br /> I certify under penalty of law that: <br /> I 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> l 2. I have personal!y 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 /> 1 Photos Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4 € 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 /> {flame' }�� c (-C[l Title <br /> Signature. Date <br /> EHD 22-02-005 Rev 08109 <br />