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01/12/2013 23:36 9169397492 CEMEX - ENVIRO PAGE 02/06 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hamlton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:wwwAgov.orgLehd <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(ETTD) 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 EKD staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate ($125). <br /> For this certification t0 be complete the operator of the site must include: <br /> • A statement documenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample results/manifests/training record's/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: (1� 11t Z013 Inspected By:1119U '(fir/_ <br /> Facility Address: 10350 S. T/zt>r�$LvD BPA ID#: L AL-600 301 9 <br /> I certify under penalty of law that: <br /> L I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 1 T have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true, ac rate, and complete: <br /> Photos Paperwork Statement <br /> 3. Tam 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: Q S (�allt��Lv7 Title: <br /> Signature: Date: <br /> EHD 22-02-005 Rcv 10-07 <br />