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• <br /> SAN JOAQUIN COUNTY • RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E.Main St.,Stockton,CA 95202-3029 JUN 0 6 2011 <br /> Telephone:(209)468-3420 Faz:(209)468-3433 Web:www.siizov.org/ehd <br /> EWRONMENTA[ HFAiTH <br /> PERMIT/SERVICES <br /> RETURN 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 violations noted in the attached Inspection Report 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 time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate ($122). <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 <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: Jr I 1111 Inspected By,rn uv> ; X10 po, )40"t U <br /> Facility Address: 90j rev Parktuay. L0.rW�EPA ID#: M,00001K3237 <br /> ca. `15330 <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 personally 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 /> X Photos DZ 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 25191) <br /> Name: IA,v, 5. Title: 5ey�C,-- rn avt(E1 e I <br /> Signature: Date: j <br /> EHD 22-02-005 v 08/10 <br />