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11/11/2010 THU 12:12 FAX 10001/020 <br /> SAN JOAQUIN COUNTY , <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.orq/eh <br /> ivu <br /> 1�2010 <br /> RETURN TO COMPLIANCE CERTIFICA,TION'l,'vjo�;, <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 <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 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: <br /> Facility Address: A,j E_ EPA ID#: 'F kk0ot 0`t S <br /> I certify under penalty of law that: <br /> s <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> I <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 Paperwork 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. (HSC 25191) <br /> Name: <br /> s <br /> Signature:: �, % r ' Date: <br /> i <br /> i <br /> , <br /> END 22-02-005 Rev 10109 <br />