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Environmental Health Department <br /> SANAOAQUIN <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MI <br /> _NQR violations noted in the"Notice to Comply" in the attached Inspection Report must be corrected within 30 days of <br /> receipt of this inspection. This certification form must be submitted to the Environmental Health Department(EHD)address at <br /> the bottom of this form within 30 days of receipt of the Inspection Report. HSC 25404.1.2(6)(11)' <br /> All corrections to other violations noted in the attached Inspection Report(IR)or Continuation Form, or disputes to any violations <br /> are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the Inspection <br /> Report. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification to be complete, the operator of the site must include: <br /> A statement documenting what corrective actions were taken or will be taken for each violation <br /> Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos verifying corrections <br /> Inspection Date: Inspected By: Ja_z3or) 6cu-ian <br /> Facility Address: Vaq l <br /> ra C4�30 CERS ID: V7 <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report-from the above-mentioned inspection date. <br /> 2, 1 have 'personally examined the following documentation submitted as proof of compliance FOR EACH VIOLATION <br /> and I believe the information to be true, accurate, and complete: <br /> Photos Y*, Paperwork-Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the possibility of a fine <br /> and/or imprisonment for known violations, (HSC 25191) <br /> Name: ArLm D—kUmuey' Title: <br /> Signature:- Date: IZ/ V�7 1-07 <br /> 4\ le--- <br /> 1868E, Hazelton Avenue l Stockton, California 952051 T 209468-34201 F 209464-0138 1 www,sjcehd.com <br />