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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3`d Floor,Stockton,CA 95202-2708 <br /> elephone:(209)468-3420 Fax:(209)468-3433 Web:www.sijzov.or2/ehd <br /> RE URN TO COMPLIANCE CERTIFICATION <br /> Any MINORolation noted in the"Notice to Comply" in the attached inspection report must be <br /> corrected with _30 da s of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health epartment(EHD)address at the top of this form within 35 days of receipt of the <br /> inspection rep <br /> All corrections o other violations noted in the attached Inspection Report(IR) or Continuation Form, or <br /> disputes to any iolatio s, are to be submitted using this certification and returned to EHD within 60 days <br /> unless otherwis sl ed in the IR. <br /> For this c ific tion to be complete the operator of the site must include: <br /> • A state ent do umenting what corrective actions were taken or will be taken for each violation <br /> • Copies f samp a results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifyi g corre ions <br /> • Operat is certi ication <br /> Inspection D e: a 13 Lx_- Inspected By: Nttt>+1✓t_Lr_- i ULV-� <br /> Facility Address: 1 3 r= I 1+�' . �r� -C EPA ID#: �AL 00y32,4-14) <br /> I certify un er pena of law that: <br /> 1. I have c rrected the violations specified in the Inspection Report from the above-mentioned <br /> inspecti n date. <br /> 2. I have p rsonall examined the following documentation submitted as proof of compliance FOR <br /> EACH IOLAT ON and I believe the information to be true, accurate, and complete: <br /> Photos x Paperwork Statement <br /> 3. I am authorized submit this certification on behalf of the Respondent. <br /> 4. 1 am aw re that t ere are significant penalties for submitting false information, including the <br /> possibili of a fi e and/or imprisonment for known violations. (HSC 25191) <br /> Name: i4/�l y 14U Title: &fttPU,4,otef &40 <br /> Signature: Date: / A�g <br /> EHD 22-02-005 Rev 1244 <br />