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08(2312013 10: 00 2099821 STOCKTONWOODSHA I GS PAGE 02 <br /> SAN JOAQUIN COUNTY REG p t� <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 € 7 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web.www siWv.org/ <br /> AUG 2 3 <br /> ENV� NME�°TAL <br /> RETURN TO COMPLIANCE CERTIFICATIt�DEPARTMENT <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 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to other violations noted in the attached Inspection Report or Continuation Form,or <br /> disputes to any violations,are to be submitted using this certification and returned to EHD within 30 dans <br /> unless otherwise spefifiedittthe Inspection Report. <br /> Note: All EIM staff a assocr ed with failing to comply by the above noted dates will be billed at <br /> the current hourly rat $125). <br /> For this certification e 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: ( Inspected By: -F)/, I )I <br /> Facility Address: EPAID##: e''ALI)L ? lh7q 8 <br /> 12� irertC6. Gam , CA <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. I 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 1KPaperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 aur 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: ke—f- U t--Z— Title: <br /> Signature: Date: <br />