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SAN JOAQUIN COUNTY '''' <br />rs <br />ENVIRONMENTAL HEALTH DEPARTMENT s <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:` <br />a , <br />0 2009 <br />RETURN TO COMPLIANCE CERTIFICATION J rgJOAQL41V <br />FzN)440 , <br />�' vr�L ry <br />Anybdl_NO_ violations noted in the "Notice to Comply" in the attached Inspection Report mus s''-'1F4ENT <br />ooriected-m4thin 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 />Ail ggrrectiorts 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 dabs will be <br />billed at the current hourly rate ($105). <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 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: (�� r�a 0 Inspected By: A R !S C ILA PIT <br />Facility Address: 790 E �Ld�(A EPA ID#: C&0 0 0 3 a 33 <br />gSayo <br />I certify under penalty of law that: <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 information to be true, accurate, and complete: <br />Photos Paperwork Statement <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: <br />Date: 0 <br />TO 39Vd A=J d QNV 0 TZ9Z69CGOZ ZS:ZO 666T/STISO <br />