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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fra: (209) 468-3433 Web: mnM.s'jzov.org/eh <br />RETURN TO COMPLIANCE CERTIFICATION <br />MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br />acted within 30 days of receipt of this inspection. This certification form must be submitted to the <br />ronmental Health Department (EHD) address at the top of this form within 35 days of receipt of the <br />action Report. <br />corrections to other violations noted in the attached Inspection Report (IR) or Continuation Form, or <br />iutes to any violations, are to be submitted using this certification and returned to EHD within 30 days <br />ss otherwise specified in the Inspection Report. <br />e: All EHD staff time associated with failing to comply by the above noted dates will be billed at <br />current hourly rate ($122). <br />r 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 />Date: July 18, 2011 <br />Address: 4219 Morada Lane <br />I certify under penalty of law that: <br />Inspected By: Garrett Backus <br />EPA ID#: <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 J�( _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 2519 1) L <br />Name:(� " �j�'r Title: a(iTp11 <br />Signature: Date: ii Ill /1 / <br />22-02-005 Rev 08/10 <br />