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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Teleph ne: (209)468-3420 Fax: (209)468-3433 Web:www.sjgov.orq/ehd <br /> RET RN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations not d in the "Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 days o receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Dep rtment (EHD) address at the top of this form within 30 days of receipt of the <br /> 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 Inspection Report. <br /> Note: All EHD staff timp associated with failing to comply by the above noted dates will be <br /> billed at the Curr nt hourly rate ($105). <br /> For this Certification t0 be Complete the operator of the site must include: <br /> • A statement documen ing what corrective actions were taken or will be taken for each violation <br /> • Copies of sample reSL Its/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certificatio <br /> Inspection Date: -r'7 Inspected By: <br /> Li <br /> Facility Address: ` ' `t�r� EPA ID#: f ilt Wv&)r71 <br /> I certify under nalty f law that: <br /> 1. I have corrected th violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally e)tamined 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 1. Paperwork _Statement <br /> 3. 1 am authori ed to slubmit this certification on behalf of the Respondent. <br /> 4. lam aware hat there are significant penalties for submitting false information, including th6 <br /> possibility o a fine Ind/or imprisonment for known violations. (HSC 25191) <br /> Name: r)�� i! 'l.`_ Title: <br /> Signature: , ; ( ' �% Date: ' ; 2vti_-0 <br /> EHD 22-02-005 Rev 08/08 <br />