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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> - Telephone:-(209)46.8-3420 Fax:(209)_468-3433.Web:www_sigov.orq/ehd <br /> RETUR, N 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. - - <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_tnspection Report. <br /> Note: All EHD staff time associated W-fth failingg t 'com ly by the above noted dates Will'be -" <br /> billed at the-curren - ourl� rate.-- -- <br /> For <br /> ate. -__C this certification to_ I the operator-of the site must include: <br /> A statement documenting what corrective actions were taken or will be taken for each violation <br /> e Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> _ verifying corrections <br /> •_Operator's certification _ <br /> Irispectiori ate: _ Inspected y: <br /> F- cili - ddr :_ _ P _ <br /> I certify under penalty of law that: <br /> -1: l have corrected the violations-specified in the Inspection Report from-the above-mentioned -- . <br /> inspection date. <br /> - 2. I have personafly-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 fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: Title: <br /> Signature: Date: <br /> EHD 22-02-005 Rev 90/09 <br />