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i <br /> SAN JOAQUIN COUNTY �w <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,St6ckton,CA 95202-3029 <br /> Telephare: (209)468-3420 Fax:(209)468-3433 Web eov.orWehd ' <br /> MAR 2 5 201, <br /> cJ <br /> RETURN TO COMPLIANCE CERTIFICATION ;A <br /> Any MINOR violations noted in the"Notice to Comply"in the attached I>tspection 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(EMD) 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 30 days <br /> unless otherwise specified in the Inspection Repots. <br /> Note: All ERD staff time associated with failing to comply by the aboe noted dates will be billed at <br /> the current hourly rate ($115). <br /> For this certification t0 be Complete the operator of the bite 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 <br /> Inspection Dater � � 1 Inspected BI : _�yU �Y Don . <br /> Facility Address: 3`i oo N 1"1 cxr � �� Dr raW EPA IDS#: L O <br /> I certify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report iorn 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 tatement <br /> 3. 1 am authorized to submit this certification on behalf of the Resp ndent. <br /> 4. 1 am aware that there are significant penalties for submitting fall information,including the <br /> possibility <br /> f ooff a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: f�g---a tMTitle: \J{p <br /> Signature: Date: �,D3 S <br /> EHD 22-02-005 Rev 11/07 <br />