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)02454 <br /> SAN JOA UIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-302.9 <br /> re/ep`?one:(209)466-3420 Pax:(209)468-3433 Web:www.sicov.ar /ehd <br /> t� <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> a <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 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 within 30 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHO staff timeassociated i failing comply by the abovenoted dates will be <br /> billed at the current h cart te. <br /> For this certification to be compthe 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 /> O erator's certification <br /> I nspection Date: �. f/ Inspected y: r,s <br /> 4c)1 Lo 1�,Z —La-1 <br /> Facilit <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 /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the,information,to lie true, accurate, and complete: <br /> Photos_Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 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 /> amen Titl ► <br /> Signature' C Cs Date } <br /> PHn lmn9.nn5 RAV n8108 <br />