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SAN JOA.QUIN COUNTY RECEWED <br />ENVIRONMENTAL HE'AL'TH DEPARTMEW <br />1868 K }fvclton Avc., Stockton, CA 95205-6232 AUG 0 <br />Telephone. (209) 468-3420 Fax: (209) 468-3433 Web: www.signor&//clid 2 2013 <br />_1=A1.VnPnp��..Es: TAL <br />llEALTH DEPARTMENT <br />RETURN TO COMPLiANCE CERTIFICATION <br />Any MINOR violations noted in the "Notice to Comply" in the attached inspection Report must be <br />corrected within 30 d�!Ys of rcccipt of this inspection. This certification form must be submitted to the <br />; nvironmcntal Health Department (EI -1,D) 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 Form, or <br />disputes to any violations, arc to he submitted using this certification and returned to T?TT17 within 10 dray. <br />unless otherwise specified in the inspection Report. <br />Note: All EHD staff time associated with railing to comply by the above noted da (cs iv ill be biller] at <br />the current hourly rate (81125). <br />For this certification t0 be COSI PI.CtC the operator or the Site must include: <br />• A statement. documenting what corrective actions were t.akcii or will be taken for each violation <br />• Copies of sample results/manifests/training records/ot.hcr appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certification <br />Inspection Date: • � � � Z_ 7-©t ."�' 11.1srected By:`Fl _L,, q • 1 rK C.�S <br />Facility Address:! 2.3_ w LO . cis � EPA f )H: C ALS 06C "Z <br />I certify under penalty of law that: <br />1. 1 have ecnTueted the viola ions specified in the Inspection Report from the above-mentioned <br />is pection date. <br />2. t have personally examined the following documentation submitted as proof of compliance FOR <br />.bACH VIOLATION and i believe the iniorrriation to be true, accurate, and cuinplctc: <br />.-Paperwork Statement <br />�. 1 ani authorized to submit this certification on behalf of the Respondent. <br />_13h.otctis <br />4. 1 ani aware that there are significant penalties for submitting false informa(ion, including the <br />possibility of a fine and/or imprisonment for known violations. (HSC 25191.) <br />Narnc: ra 01-� <br />6.3 -or )"011 _. ---Title: <br />G N4f Y'.. <br />EM 22-02-005 Rev 10-07 <br />aged 1W ev;0> £i•/Z0/80 <br />