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r S <br /> San Joaquin County <br /> Environmental Health Department <br /> 1868 East Hazelton Avenue, Stockton, California95205-6232 <br /> f' <br /> Telephone.(209)468-3420 Fax: (209)468-3433 Web.www.sigov.oro/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD) address <br /> the top of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other violations noted in the attached Inspection Report(IR) or Continuation Form, or disputes to any i <br /> violations, are to be submitted using this certification and returned to EHDwithin 30 days unless otherwise specified in the ; <br /> 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 complete,the operator of the site must include: <br /> A statement documenting what corrective actions were taken or will be taken for each violation i <br /> Copies of sample results/manifests/training recordslother appropriate paperwork, and/or photos verifying correction; r <br /> Inspection Date: y -4 Inspected By:—i i 7 il� h�id ,ii <br /> Facility Address: ii .� li<Ir , is i;= ,�' i i , .� ; 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 inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATIONI, <br /> I believe the information to be true, accurate, and complete: ' <br /> Photos Paperwork Statement <br /> i <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. i <br /> i <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine and/ <br /> imprisonment for known violations. (HSC 25191) <br /> `/I OF v' <br /> Name: '-04 � ~�Z A (�_ Title: �-ELr o <br /> Signature: Date: �- '� 7), <br /> I <br /> I' <br />