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M <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazeiton Avenue, Stockton, California 95205-6232 <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. HSC 25404.1.2(c)(1) <br />All corrections to o her 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. HSC 25185(c)(3) <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed 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 results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />0KN•*3 *TC7K#Mi (I f W-1 <br />Inspection Date: June 221 , 12012- <br />I <br />Inspected By:,__,atrreL-1L <br />F:PJ-,l I <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentiorygit <br />inspection date. <br />Photos Par)erwork StatemeM <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 />Name: q /,tPy Title: (O ,, <br />Sicinature, Ja e -_C! Date: 7),:9 4/ <br />EHD 22-02-005 Rev 04119112 <br />