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SAN JOAQUIN COUNTY <br /> ENVIRONNIFNTALI-IEALTH DEPARTMENT <br /> 600 DIV Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)469-3420 Fax:(209)468-343:.1 Web.ww%v.sjeov.nrn/eh! <br /> RETURN 'ro COMPLIANCE CERTIFICATION <br /> Any;v_3[NOR violations noted in the"Notice to Comply' in the attached inspection report must be <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.35 days of receipt of the <br /> inspection report. <br /> All corrections toother 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 EFID within 00—da s <br /> unless otherwise specified in the IR. <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/traitiing records/other appropriate;paperwork, and/or photos <br /> verifying corrections <br /> as Operator's certification <br /> Inspection Date: ' �3 Inspected E3 vae <br /> Facility Adairess;..__�" 1�+t^! ... EPA€PA II)#e���z? <br /> t ceztity under penalty of law that: <br /> I. i. have corrceted Lite violations specified in the Inspection Report from the above-mentioned � <br /> inspection date. I� <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to lie true, accurate, and complete: <br /> ---.Photoe; .__-.jt._......Pape•worl< Statement <br /> 3. 1 tam authorized to submit this certification on behalf of the Respondent. <br /> 1 <br /> i 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. (IiSC 25191) <br /> I <br /> } <br /> Natne:��-/ T_.�,�..__ Title: <br /> _....._Signature; -.._..—_.__�.... _ —_...--- .....__..__.... Date: " ..__._..._....._.. - I <br /> EHD 22-02-005 Rev 05/07 <br />