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i SAN JOAQUIN COUNTY , NVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton,CA 95202-3029 Telep ne:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org_/ehd RETU TO COMPLIANCE CERTIFICATION Any MINOR violations not d in the"Notice to Comply"in the attached Inspection Report must be corrected within 30 days of receipt of this inspection. This certification form must be submitted to the Environmental Health Department (EHD) address at the top of this form within 35 days of receipt of the Inspection Report. All corrections to other viol tions noted in the attached Inspection Report (IR) or Continuation Form, or disputes to any violations, e to be submitted using this certification and returned to EHD within 30 days unless otherwise specified i the Inspection Report. Note: All EHD staff time ssociated with failing to comply by the above noted dates will be billed at the current hourly rate. For this Cer tif1Cat10 t0 be complete the operator of the site must include: / • A statement docume ting what corrective actions were taken or will be taken for each violation • Copies of sample re ults/manifests/training records/other appropriate paperwork, and/or photos verifying correction • Operator's certificat' n Inspection Date: Inspected By: Facility Address: 4 '_ w�-i EPA ID#: (dt- I certify under penalty o law that: 1. I have corrected the violations specified in the Inspection Report from the above-mentioned inspection date. 2. I have personally ex ined the following documentation submitted as proof of compliance FOR EACH VIOLATION and I believe the information to be true, accurate, and complete: Photos Paperwork Statement 3. I am authorized to su mit this certification on behalf of the Respondent. 4. I am aware that there are significant penalties for submitting false information, including the possibility of a fine or imprisonment for known violations. (HSC 25191) Name: i, �r`'� ' Title: CJV•w�` Signature: '; r, Date: <� EHD 22-02-005 Rev 11/07