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SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fav:(209)468-3433 Web:www.si gy.or 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 35 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 vto ations, aze to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwrse 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($122). <br /> For this CertI JCatIon t0 be Complete the operator of the site const include: <br /> • A statement documentingg what corrective actions were taken or will be taken for each violation <br /> • Copies of sample results/m anifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification d�j <br /> Inspection Date: t `�b Inspected ,B��y::((J�qI S �N `►1( <br /> Facility Address: S 1 USI W Lai (A EPA ID#: �./`iU 01 <br /> 1 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 I 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 a fine and/or imprisonment for known violations. (HSC 2519 1) <br /> Name: t Title: p,NtcrS �eyj sp <br /> Signatur 1-61 Date: <br /> EHD 22-02-005 Rev 08/10 <br /> OCT 05 2011 <br /> gAN joAQu,N COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />