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002454 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telept'.one: (209) 468-3420 Fax: (209) 468-3433 Web:www.s ov.or /e <br /> CEI 16` ED <br /> RETURN TO COMPLIANCE CERTIFICATION NOV 2 2 2010 <br /> ENVIRONMENTAL HEALTH <br /> Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report &OERVICES, <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 30 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 Report. <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 /> i <br /> For 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 /> Inspection Date: 10/19/2010 Inspected By: Aris Cacapit <br /> 24124 North Bruella Road <br /> Facility Address: Acampo CA 95220 EPA ID#: CAL000216468 <br /> I I <br /> I certify under penalty of law that: j <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the-inform atioa to be true, accurate, and complete: <br /> X Photos X Paperwork X Statement <br /> I <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4 1 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' Karen Kammerer Title: District Secretary <br /> i <br /> Signature. Date- 11/18/2010 <br /> EHD 22-02-005 Rev 08/08 <br />