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. i <br /> SAN JOAQV u\COUNTY <br /> ENviRoNmENrAL HEALTH DF.PAP TMENT <br /> 600 Rint Main Sftak Stockton,CA 95202 <br /> Tekphone.(209)468-3420 Fax:(209)468.3433 Web: www.sjoc v.or ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached inspection report must be connected <br /> within 30 days of receipt of this inspection. This certification form must be submitted to the Environmental <br /> Health Department(EHD)address at the top of this form within 35 days of receipt of the 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 IR. <br /> For this certification to beCOMPIete 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 Dater v l Inspected By: Dnjat jTr <br /> Facility Address: 77 EPA <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I 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 /> 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&e and/or imprisonment for known violations. (HSC 2519 1) <br /> Name: Title: 1enr".Z— <br /> Signature:__ Date: 0-�n lC�) <br /> C00[n VNIM OQi HHD ZC90 ZZ5 M xVa ST:6T 0T09/6Z/C0 <br />