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01/11/2011 17:49 2093337676A ONE GAS FOOD PAGE 04/04 <br />SAN JOAQUIN COUNTY J <br />ENVIRONMENTAL HEALTH DEPARTMENT y` <br />600 East Main Street, Stockton, CA 95202-3029 ' <br />Fel hone' (209) 468-3420 Fax: (209) 46a-3433 Web: wwW.sj oq�v_ora/ehd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any MINOR violations oted in the "Notice to Comply' in the attached Inspection Report must be <br />corrected within 30 da s 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. I I <br />All corrections to other violatidns noted in the attached Inspection Report (IR) or Continuation Form, or <br />disputes to any violations, arejto be submitted using this certification and retumed to EHD within 30 days <br />unless otherwise specified in the Inspection Report, <br />Note: All EHD staff `ime associated with failing to comply by the above noted dates will be <br />billed at the c rrenld hourly rate. <br />For this certifi atioh 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 sults/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />• Operator's certifi calt <br />ion <br />Inspection Date:, Inspected By: ( '7 7- j-4 ' <br />Facility Address: l-�- iLZ- &)irTf jiile EPA ID#�j., 06b3 10 j r4 <br />I certify under penal of law that: <br />1. I have corrected the violations specified in the inspection Report from the above-mentioned <br />inspection date. <br />2. 1 have personaN examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATI N and I believe the information to be true, accurate, and complete - <br />Photos Paperwork Statement <br />3. 1 am authorized t� 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 fin D and/or imprisonment for known violations. (HSC 25191) <br />Name: ? Title: AA 42-r <br />Signature: <br />EHD 22.02-005 Rev ,0/C9 <br />Date:.--- <br />cs L <br />