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06/":3/2009 02:05 2097273120 PAGE 07/07 <br />9-1 • RIEC OVE[i <br />SAN JOAQUIN COUNTY - <br />ENVIRONMENTAL HEALTH DEPARTMENT APR 2 Q 2010 <br />600 East Main Street,Stockton,' CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www si4ov ENT HEALTH <br />PERMIT/SERVICES <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 falling to comply by the above noted dates will be <br />billed at the current hourly rate. <br />For this certification to be complete the operator -of the site must include: <br />A statement documenting what oorrective 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: �� S` l Inspected By: AZ,S ?ca� f <br />Facility Address: �7 D0 I "^ 8 EPA ID#: (,/7 L <br />I certify under penalty of taw 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 t/Paperwork v / 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 fine and/or imprisonment for known violations. (HS//C_ 25191) J(� <br />Name: � � �i1t°Vcv>°!2 Title: al' kfia ,ce Ana <br />Sit <br />6140 22.02.005 Rev 10109 <br />Date: q-,20 - / o <br />