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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEN <br />600 East Main Street, Stockton, CA 95202 <br />Telephone: (209) 468-3420 Fat: (209) 468=3433 Web: www.sj og v.or /g ehd <br />RETURN ,, COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached inspection report must be corrected <br />within 30 days of receipt of this inspection. This certification form must be submitted to the Environmental <br />Health Department (EHD) 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 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 IR. <br />For this Certification t0 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 />Inspection Date: 4/1/08 Inspected By: Michelle Henry <br />Facility d. D 111 4:: <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 />Photos X Paperwork X Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4. I 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: Eric Munns <br />Title: HESSpecialist <br />Signature: Date: m" <br />