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06/16/2005 20:09 2094664090 SALAZARS QTW PAGE 02 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 Fast Weber Avenue,3rd Floor,Stockton,CA 95202-2708 <br /> Telephone.,(209)468-3420 Pax:(209)468-3433 Web:ww ,sigov.oM ehd <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 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 th <br /> inspection report. <br /> All corrections to other violations noted in the attached Inspection Report(IR) or Continuation Form,o <br /> disputes to any violations,are to be submitted using this certification and returned to EHD within 60 da Ls <br /> unless otherwise specified in the IR. <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 betaken 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: Inspected By: 9-Al+wl ra VZ'i r_i Ui4 <br /> Facility Address:l 22 f. Alto tiJ V EPA ID#: AG ODDa� /!ol <br /> I certify under penalty of law that: <br /> I. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOI <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. I am aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine and/or imprisonment for known violations. (FISC 2519 1) <br /> Name: /{MAQ(rtf#J0 S 41A 7A1L Title: OLkM C f <br /> Signature• Date: Ab t- R <br /> EHD 22-02-005 Rev 12-04 <br />