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Aug. 19. 2013 2:06PM No. 0924 P. 1 <br /> SAN SOAQUIN COUNTY <br /> ENVIRON1v1EN'X'.AT.HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone.(209)468-3420 Fax,(209)468-3433 Web.www.sjgov.or�l�h� <br /> RETURN TO COMPLIANCE CERTIFICtATIOIV <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be <br /> corrected within 30 dans of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department(RHD)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 Foxm,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($125). <br /> For this CellifICat1011 to be Complete the operator of the site must include: <br /> v 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: WspectedBy: , cr'o <br /> Harm Szo pm6 T <br /> Facility Address, 1!�;a CT_ tjre.,m,� EPA ID9: GA-0 9-a*3�26,2 <br /> I certify under penalty of law that: <br /> 1, 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> itspeetion date. <br /> 2. 1 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 _Fapexwork Statement <br /> 3, lam authorized to submit thus 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 ituprisonment for laiown violations. (RSC 25191) <br /> -Name: Title,, <br /> Signature: Late <br /> — nn nnr — .,... 1 n An <br />