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OG/11/2010 16 04 FAX 2093589230 SR7IFT SHOP LATHROP 1&002/007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 Past Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.slgov.orjZ/ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply" in the attached Inspection Report must be <br /> ctlrrected 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 /> Ipspechon Report. <br /> All corn ions 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 tkw associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate($98). <br /> For this certification t0 be COnlplete the operator of the site must include: <br /> a A statement documenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample resultslmanifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: 61 I C212-010 Inspected By: <br /> Facility Address: q 0 t 1)4feS/ FatyI -Lkjo,v EPA ID#: OMR M00F3Z87 <br /> Lnxlwop, CW. a5336 <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personailly examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true, accurate, and complete: <br /> Photos X Paperwork K Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4, I am aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25J 91) <br /> Name: o�n.� IJ r`e•�J$ S Title: Q rJ /� t'►�y 1' <br /> Signature: Date: <br /> EHD 22-02-005 Rev 11/07 <br />