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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sicjov.org/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 30 days of receipt of the <br /> Inspection Report. <br /> All corrections 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 b 0Mbov,0,, te'd date t will be <br /> billed at the current hourly rate ($105). <br /> DEC l 7 2008 <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 tokmfar each.miniation <br /> • Copies of sample results/manifestsltraining recordslother appropriate pa ` r hotos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: HCl��� �0� Inspected By: <br /> Facility Add ress:Ll Vf�_ A EPA ID#: ryL, <br /> I certify under penalty of law that: <br /> 1. l 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: r�u � ,' ^ t��, Title: <br /> Signature: � f��;�,,-�__�� �._�... <br /> Date: i-,_ 1Y <br /> r <br /> Si <br /> EHD 22-02-005 Rev 08108 <br /> L'd ZZLt99t,60Z aieday otny suenr <br />