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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 JUL 13 2009 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sieov.org/ehd <br /> SAN JOAOU1N COUNTY <br /> IL <br /> EALTH DEPAgT NT <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 billed at <br /> the current hourly 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 /> • <br /> Operator's certification <br /> Inspection Date: (e�/l(o l ;Z00y Inspected By: 4r is a e /%L <br /> Facility Address: `61+f 1-1 (14r "k EPA ID#: C A— L D©© �O t� <br /> 461cl i Cly- Cl5o2L(0 <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. I have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and 1 believe the information to be true, accurate, and complete: <br /> _'Photos ) Paperwork Statement <br /> 3. I 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 fine and/or imprisonment for known violations. (HSC 25191) <br /> �- / <br /> Name: 4Glc..c!/ Title: �r✓��-e ,4.o/��S0W1- <br /> Signature: Date: fhqlai <br /> EHD 22-02-005 Rev 08/08 <br />