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SAN JOAQUIN COUNTY RECL,_ tii hD <br />r.NVIRONMENTAL HEALTH DEPARTMENT L� <br />304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/eh JUL. 1 D 2006 <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 (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 completethe 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: Inspected By: <br />Facility Address: &2y A/21712 c,r, 5nc,1e/&,9PA ID# <br />I certify under penalty of law that: <br />C44- 00L0 -7�-5Jr1 <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 V_ Paperwork LIZ'* <br />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:=UiJ n%�i���"�.=7 y Title: <br />Si <br />EHD 22-02-005 Rev 12-04 <br />Date: ./ -(! � -61 (­ <br />