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002454 • R�- 3 REVED <br /> V <br /> SAN JOAQUIN COUNTY AUG 3 0 iUIU <br /> ENVIRONMENTAL, HFAI TH DFPARTMENT ENVIROMIENT HEALTH <br /> 600 East Main Street, Stockton, CA 95202-3029 PERMIT/SERVI'CES <br /> Telep`one: (1209) 458-3420 Pax:!209i 468-3433 Web:www.sigov.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 by the above noted dates will be <br /> billed at the current hourly rate. <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 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 Date: +3�j /�3 /2.0/0 Inspected By:A S (?SL40,1T <br /> Facility Address:620s.c!/,i� ,(.�✓� Gip. EPA ID#: CAD5?835EW320 <br /> I 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 and I believe the-information to be true, accurate, and complete: <br /> Photos mPaperwork__,�tatement <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: _LQT Title: yt/�:/ �� �N/.O� t/ • .✓� a� <br /> Signatur Date 09 0 /0 <br /> EHD 22-02-005 Rev 08108 <br />