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0 SAN JOAQUIN COUNTY 0 -1 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.siqov.o[g/ehd <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 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 EHD staff time associated with fang • comply by the above noted dates will be <br />• at the current hourly rate. <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 />• Copies of sample resufts/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• UDerator's CertlTication <br />I certify under penalty of law that: <br />ITIrTITT47410T <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 be true, accurate, and complete: <br />Photos Paperwork Statement <br />4. t 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 />L2 <br />EHD 22-02-005 Rev 08/08 <br />,Title: <br />no <br />