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SANJOAQUIN COUN V) <br /> NA I RONNILN1 AI..I I I,-.A I..III DLIPA!:I'M!. ,I <br /> 600 1�, M;im St„ S(ockton, CA 95"O2 3()N <br /> Telephww.-(200 1 468-.1420 Fax:(209)466 .1433 1 Veh; ww,jguvmigd I d <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 (FI ID) 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 E.1 11) within 30 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EH D staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate ($98). <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 rcsults/manj fe.sts/training records/other appropriate paperwork, and/or Photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: Z Inspected BY: <br /> Facility Address: em4 k47 Ylae_,e <br /> , _0 I <br /> EPA 1[)f#: GAlDOO <br /> 1 certify under penalty of law that: <br /> I. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. 1 <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—,.X Paperwork X 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 fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: 1'itle: <br /> Signature: Datc: <br /> EHI) 22-02-005 Rev 10-07 <br />