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SAN JOAQUIN COUNTY <br /> FNVIRONMENTAI_HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(203)468-3420 Fax_(209)468-3433 Web:wwwsioPvYXTglehd <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 19j& <br /> ys of receipt of this inspection. This certificatlon form must be submitted to the <br /> Environmental Health Depa,-tment(EI O)address at the top of this form within 30 days of receipt of the <br /> Inspection Report. HSC 25404.1.2(c)(1) <br /> All corrections to other violations noted in the attached Inspection Report(I R) 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. HSC 25135(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 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 resultslmanifestsdtralning recordslother appropriate paperwork, and/ar photas <br /> verifying corrections <br /> ® Operator's certification <br /> Inspection Date_ g 012 �- Inspected By-Stacy Rivera <br /> Facility Address: Q-q W +Ylcl)¢ru,�W *-j EPA ID#: D©C,? <br /> 5ToC-K7-o, 4'5106 <br /> I certify under penalty of law that: <br /> 1. t 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 l believe the information to be true, accurate, and complete: <br /> X Photos_ x Paperwork,_X_Statemunt <br /> 3. lam authorized to submit this certification on behalf of the Respondent. <br /> 4. lam aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25'191) <br /> Name: w fJ �c4 S c� Title:_ M A lyI �r`1c;Y� — <br /> Signature: _ v�-.� Date: E!/3/z b 13- <br /> EHD U-02-005 Rev 091'i 1 <br />