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10/14/2011 t'RI 9: 06 PALL 203433 6JC EHD <br /> ®005/005 <br /> OCT 17 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HFALTkIs Vj%,r . <br /> 600 E.Main$L,Stockton,CA`96202r9�Q <br /> Telephone:(209)468-3420 Pax:(209)468--Maalw'o_ ' /' v, r /;hd <br /> V� <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 30days 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 t er vio ons noted in the attached Inspection Report or Continuation Form,or <br /> disputes to any violations,are to be submitted using this certification and returned to EHD wi 30 dans <br /> unless otherwise specified in the Inspection Report, "— <br /> Note: ,All EHD staff tine associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate($125). <br /> For this certification to be COITIPlCte 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 Data;: Ct 12-l�/1� Inspected By _77omax) <br /> Facility A.ddress:Z 630 AEPA,ID##:Crit_ 000 3(a`7c' S f-3 <br /> -0 t90 -irac'7�, C" g c,Y. <br /> I certify under penalty 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 personally examined the following documentation submitted as proof of compliance FOR <br /> FACH'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 line and/or imprisonment for known violations.(HSC 2S 191) <br /> NameA , Svc c't2 v Title: 0(c ,Nr�,/'` <br /> Signature: <br /> Date: /0//-7// <br /> EHD 22-02-005 Rev 08/10 <br /> T /T =Vd 5L886E'S60Z Sx010W NHVECZnx ria ET : CO TT02: LT '-430 <br />