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4 - • SAN JOAQUIN COUNTY • ° "� ����� <br />ENVIRONMENTAL HEALTH DEPARTMENT g 2007 <br />304 East Weber Avenue, 3`" Floor, Stockton, CA 95202-2708 FEB <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si2ov.orgjehd ENVIRONMENT HEAE(H <br />ot:aweITISERVICES <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 (IR) or Continuation Form, or <br />disputes to any violations, are to be submitted using this certification and returned to EHD within 60 days <br />unless otherwise specified in the IR. <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 records/other appropriate paperwork, and/or photos <br />verifying corrections _ e� <br />• Operator's certification <br />Inspection Date: D - A4-03 Inspected By: %Om uknr <br />Facility Address: X34, S %'�, �� (. EPA ID#: <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 />Photos Paperwork ✓ 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: <br />r r W V +Vv�� <br />A t", hn. ho! w L tVrta&t& 4r <br />EHD 22-02-005 Rev 12-04 <br />e Qk-nJlen\� L akx <br />Title: ow w W <br />Date: .tl , aN -Oi <br />@w,�lo « 4vrttA irk <br />X WWI— V�- <br />