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SAN JOAQUIN COUNTY Iwo, <br /> ENVIRONMENTAL HEALTH RECEIVED <br /> DEPARTMENT , `E C E I V E D <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 F¢ .-(209)468-3433 Web:www.sie�ehd AUG 3 1 2011 <br /> PERMIT/SERVICESLTM <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 (a <br /> Environmental Health Department(EHD)address at the top of this form within 35 days of receipt of the '1 <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 0 <br /> unless otherwise specified in the Inspection Report. C <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate($122). <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 /> F <br /> ction Date: �� 2 l Inspected By: J-e-Fr-e} Ivo`ty Address: �-.� � '�/- qr�'I na iEPAID#: CA �-- 0 0 Gertify 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 /> c <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOR 1 <br /> EACH VIOLATION a7Photos <br /> elieve the info�ation to be true, ace ate, and complete: <br /> V Paperwork�tement <br /> 3. I 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. (HSC 25191) ,, _ -f J <br /> Name: ✓ r/f N Title: � CZ ry `JG f� +�1 S <br /> Signature: ) r�1 a(e <br /> Date: d ` 0 ✓� <br /> EHD 22-02-005 Rev 08/10 ���� S Znn� Cody 4�1 i Irl <br />