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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)466-31133 Web:www.sjgov.o!M&W <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be <br /> correctgd:W hin 30 days of receipt of this inspection. This certification form must to 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..r <br /> Note: All EHD staff time associated with failing,o comply by the'above noted dates will be <br /> billed at the current hourly-rate. <br /> For,this Certification t0 be Compute 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 resuftstmanifests/training recordslother appropriate paperwork, andlor photos <br /> verifying corrections - <br /> • Operator's certification <br /> Inspection Date: tj / — /p tnspe d° y: 64C N.S <br /> Facility Address: 93 21 c EISA 1 CAL 040 OY3338" <br /> I certify under penalty of law that: <br /> 1. t 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 1 believe the information to be true, accurate, and complete: <br /> Photos Paperwork ✓ Statement <br /> 3. I 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 imprisonment for known violations. (HSC 25191) <br /> Name: �i6�e �03t2 Lt3 Title: int c�d2 ✓i/. ��5' <br /> Signature: Date: <br /> END 22-02-005 Rev 10/09 <br /> 1 <br />