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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Tel hone:(209)468-3420 Fax.(209)468-3433 Web:www.sigov.org/ehd <br /> RET RN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations n ted in the"Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 days f <br /> lth receipt of this inspection. This certification form must be submitted to the <br /> Environmental HeaDe artment(EHD) address at the top of this form within 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to other vi lations 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 specifi in the Inspection Report. <br /> Note: All EHD staff ti associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate. <br /> For this Certlflcat on t0 be complete the operator of the site must include: I <br /> • A statement docu enting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample esults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying correcti ns <br /> • Operator's certifu ation <br /> Inspection Date: <) glpg Inspected By: RO►(1 Ito-4 I <br /> Facility Address: V'S�, 9 {'!0Af,CA % EPA ID#: C,N-000,)Z+�g40 <br /> I certify under penalt of law that: <br /> 1. I have corrected t e violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally xamined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATI N and I believe the information to be true, accurate, and complete: <br /> _Photos t% Paperwork V Statement <br /> 3. 1 am authorized t submit this certification on behalf of the Respondent. <br /> 4. I am aware that th re are significant penalties for submitting false information, including the <br /> possibility of a fu and/or imprisonment for known violations. (HSC 25191) <br /> Name: t+i' Title: Wv�t(, Gp `Q( #,! <br /> Signature: Date: <br /> 1 109 <br /> EHD 22-02-005 Rev 1 <br />