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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue , Stockton , California 95205 - 6232 Telephone : ( 209 ) 468 - 3420 Fax: ( 209 ) 468- 3433 Web : www . sigov . org/ehd RETURN TO COMPLIANCE CERTIFICATION Any MINOR violations noted 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 30 days of receipt of the Inspection Report , HSC 25404 . 1 . 2 ( c) ( 1 ) All corrections to other violations noted in the attached Inspection Report ( IR) or Continuation Form , or disputes to any violations , are to be submitted using this certification and returned to EHD within 30 days unless otherwise specified in the Inspection Report . HSC 25185 ( c) ( 3 ) Note : All EHD staff time associated with failing to comply by the above noted dates will be billed at the current hourly rate . For this Certification t0 be Complete the operator of the site must include : • A statement documenting what corrective actions were taken or will be taken for each violation • Copies of sample results/manifests/training records/other appropriate paperwork , and/or photos verifying corrections • Operator' s certification Inspection Date : Inspected By . Facility Address : EPA ID# : I certify under penalty of law that : 1 . I have corrected the violations specified in the Inspection Report from the above - mentioned inspection date . 2 . I have personally examined 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 . 1 am authorized to submit this certification on behalf of the Respondent . 4 . 1 am aware that there are significant penalties for submitting false information , including the possibility of a fine and/or imprisonment for known violations . ( HSC 25191 ) Name : Title : Signature : Date : EHD 22-02-005 Rev 4/12