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'03/01/2012 17:01 2099434709 7 1/1 MATERIALS PAGE 04 <br />SAN JOAQUfN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />900 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: w+.aw.si9ov&g19hd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINA violations noted in the 'Notice b Comply" in the attached Inspection Report must be <br />��d within30 days of receipt of this inspection. This cerification form must be submitted to the <br />Environmental Health Department (EHO) address at the top of this form within 30 days of receipt of the <br />Inspection Report. HSC 25404.1.2(c)(1) <br />Ail qorrei2fl.§to other vi-Qlatiqr§ 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 EMD within 30 days <br />unless otherwise specified in the Inspection Report, HSC 25185(c)(3) <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be <br />billed at the current hourly rate, <br />For this certification t0 be Complete the operator of the site must include: <br />A statement documenting what corrective actions were taken or will be taken for each vlolstlon <br />• Gopies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: 13(:)Il �. <br />1 Facility Address: T i� <br />Stock i�cn CR, 95.15 <br />I certify under penalty of law that: <br />Inspected By: S cY Rivera <br />EPA ID#: C/N LOQ N (_'fid <br />1, I h8ve corrected the violations specified in the Inspection Report From the above-mentloned <br />inspection date. V61Ckt 's have or crQ b�r, <br />�g c:orr�ctEu <br />gCccyt'o,gnce w�fh +'F►L O;cl�e SPpc'.�;Qd •n %h ct+ r <br />Z. I haus personalty examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLAT{ON rind I believe the information to be true, accurate, and complete: <br />Photos ✓ Paperwork_V Statement <br />3. I am authorized to submit this certification on behalf of the Respondent. <br />4, f 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:_ 1 v1 CQ SGh� `�y Title: <br />Signature: <br />ero z2.u41os,R­n ,. <br />Date: 3 ! � f t <br />