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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202 <br /> Telephone.(209)468.3420,Fax.°(209)468-3433 Weh:www.sigov.ora/chd <br /> RETURN TO COMPLIANCE IC TI <br /> Any MINOR violations noted in the"Notice to Comply"in the attached inspection report must be rte ,ed <br /> within 30 days of receipt of this inspection. This certification form must be submitted to the Environmental <br /> Health Department(F-RD)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 Foran,or <br /> disputes to any violations,are to be submitted using this certification and returned to EHD within 30 dans <br /> unless otherwise specified in the IR. <br /> OT this certification t4 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 <br /> • Copies of sample results/manifests/training records/other appropriate paperwork,and/or photos <br /> verifying corrections <br /> Operator's certification <br /> In.spr. <br /> ection Dater 1 Inspected y: c.�.ekke <br /> Facility Address: o 1 t-j __ <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 /> v <br /> Photos Paperwork Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent <br /> 4. I am aware that there are sigiiif cant penalties for submitting false information,including the <br /> possibility of fine and/or imprisonment for known violations. (HSC 25191) <br /> Name• A - Title: Tc l <br /> Signature:_ - Date: <br /> £OOQ� VMIDV OQ2i HED Z£90 ZZS SZ6 %v3 TT:£T OTOZ/ZO/£O <br />