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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Tele hone:(209)468-3420 Fax:(209)468-3433 Web:vw sigov.org/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations n�joted in the "Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 davfi 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. HSC 25404.1.2(c)(1) <br /> All corrections to other Violations noted in the attached Inspection Report(IR)or Continuation Form, or <br /> disputes to any violation11 s, are to be submitted using this certification and returned to EHD within 30 clays <br /> unless otherwise specified in the Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff t`me associated with failing to comply by the above noted dates will be <br /> billed at the c rrent hourly rate. <br /> For this certificption to be complete the operator of the site must include: <br /> • A statement docu enting what corrective actions were taken or will be taken for each violation <br /> • Copies of sampler sults/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying correction <br /> • Operator's certifica on <br /> Inspection Date: j / Inspected By:Stacy Rivera <br /> Facility Address: 8 3 L ocur,6 EPA ID#: C—AtL oc1 )o D-4Sa qp <br /> I certify under penalt� of law that: <br /> 1. 1 have corrected he violations specified in the Inspection Report from the above-mentioned <br /> inspection elate. <br /> 2. 1 have personally examined 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 Y,_Paperwork \ Statement <br /> 3. 1 am authorized It submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that t ere are significant penalties for submitting false information, including the <br /> possibility of a fino and/or imprisonment for known violations. (HSC 25191) <br /> Name: Title: mA2 . ��: <br /> Signature: u Date: Z <br /> FHD 22.02.005 Rev 09/11 <br />