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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTNIENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fux: (209) 468-3433 Web: wwwsrgov.orgJeM <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report trust 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. 4' <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 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 (5122). <br />For this certification t0 be COMPIete the operator of the site must include: <br />• A statement documenting what corrective actions were taken or will betaken for each violation <br />• Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification w <br />/f <br />Inspection Date: + • �$• _ Inspected By: -T k4L 2a <br />Facility Address: ftp iS L,�. 12,tn�_ :i EPA ID#: �L bda �ciif `i <br />I certify under penalty of law that: -�d0-- JE..4C�_ PN +-flL <br />-NTS Ar <br />1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br />inspection date. 4.es -� '3�6 Ay S <br />2, 1 have person amincd the following documentations as proof of compliance .FOR <br />EACH VIOLATION an eve the inform e true, accurate, and complete: <br />tos t vork Statement <br />3. lam auth to sub in this certification on behalf of the dn�ent. <br />4. 1 am aware that there are significant tes for submitting false information, including the <br />possibility of a fine and/o risonment for violations. (HSC 25191) <br />� n 1 <br />Name:A �C Title: <br />---,----Signature:_ �t � �A— Lz z kP4 Date: <br />EHD 22-02-005 Rev 08/10 <br />