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0 SAN JOA UI COUNTY 0 <br />ENvIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 -Web: www.sjgov.preehd <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 (EHI)) address at the top of this 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 />unless otherwise specified in the IR. <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 results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />00044RUMOM <br />mnmma�� <br />I certify under penalty of law that: <br />NIKM3=10 :' , <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. <br />V I have personally examined the following documentation'submitted as proof of compliance FO <br />EACH VIOLATION andl believe the information to be true, I accurate, and complete: <br />.Photos Paperwork Statement <br />3. 1 am authorized to submit this cbrtification on behalf of the Respondent. <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 />A= <br />EHD 22-02-005 Rev 051% <br />M <br />Im <br />MKIM <br />M <br />