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i <br /> SAN JOAQUIN C OITNTv <br /> ENVIRONMENTAL HEAT-TH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Trleph ne:(209)468-3420 Fax:(209)468-3433 Web: www sigy.,� ui olid <br /> RF,TURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to Comply" in the attached inspection report must be <br /> corrected-within 30 days 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 35 days of receipt of the <br /> inspection report. <br /> All corrections to other viola)ions 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 60 dans <br /> unless otherwise specified in the IR. <br /> For this CertificatiO t0 be COmplete the operator of the site must include: <br /> • A statement docume ting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample res its/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying;corrections <br /> • Operator's certificati n <br /> f Inspection Date: Inspected By: hi : etc 1l e (nom <br /> Facility Address: o- 4 ► EPA YD#: Gr"rL 0 0 2g7 UZ <br /> I certify under penalty o law that: <br /> 1. 1 have corrected the iolations specified in the Inspection Report from the above-mentioned <br /> } inspection date. <br /> 2. I have person ly cxined the following documentation submitted as proof of compliance FOR <br /> EACH VIO TIONandI believe the information to be true, accurate, and complete: <br /> Photos �- Paperwork ✓ Statement <br /> 3. lam authoriz to su mit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting take information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: {' T Z l'itle: Wa' <br /> Signature: Date: <br /> __G0 _Ed d 3,0,�GSAIi N Z9aZZ686aZ Zb :60 L'00Z/8TIZT <br />