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... WJUIZ/UIZ <br /> SMJOAQULNCOUNTY - <br /> EDNIRONNIENTAL HEALTH DEPARTMENT <br /> 606 East Main Street.Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fox:(209)468-3433 Web:www.algov.orclehd <br /> RETURM 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 /> Uwwonmentat Health Department(ERD)address at the top of this form within 30 days of receipt of the <br /> Inspection Report. <br /> All corrections to otherviolafiora noted in the attached irnpection 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 /> U.,less otherwietr"W11e6 ir+"lrwpection Report <br /> Note. AN EHD staff dere associated with fading to comply by tiro above noted dates will be <br /> billed at the cowent howly rate. <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/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> e Operator's certification <br /> Inspection Datec—AL \21V� InspectedBtr: U � <br /> Facility Address: I(,400 EPA 10M L AW OOZ1-'6,j32- <br /> 1 certify under penalty of law that: <br /> 1 1 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 an dd l tr eve 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 submit ing false information, including the <br /> possibility of a fine and/or imprisonment for knownviofafions. (HSC 25191) <br /> Name: AG4CrM <br /> Signature: 7 d, Date: <br /> EHD 22-02-ON Rev 08/08 <br />