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SAN JOAQUIN COUNTY <br /> SNVIPLONMBNTAL 14EALT9 DOAMUriNT <br /> 304 East Weber Avenue,Yd Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax!(209)469-3433 Web:nMMLsjV-V--0—f9/e-kd- <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached inspection report must be <br /> corrected withinL30 days of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department(ED) 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 /> g <br /> disputes to any violations,are to be submitted using this certification and returned to EHD within 60&, <br /> unless otherwise specified in the IR. <br /> For this certification to be complete the operator of the site must include: <br /> • A statement documenting what corrective actions were taken or will be taken for each violati"On <br /> • Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: 0 Inspected By: <br /> 0 <br /> Facility Address: ✓ EPA ID#:- <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 t.o.,be true, accurate, and complete: <br /> Photos Paperwork 'Statement. <br /> 3. 1 am authorized to submit this certification 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 imp ri5onment for known violations. (HSC 25 19 1) <br /> Title:itle: <br /> Signature: Date: <br />