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i <br /> 1/ SAN JOAQUIN COUNTY V <br /> ENVIRONMENTAL HEALTH DEPARTMENT RE COWED <br /> 304 East Weber Avenue,3rd Floor,Stockton, CA 95202-2708 <br /> Telephone.(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.ore/ehd MAA J 2006 <br /> LTH <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 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 violations, are to be submitted using this certification and returned to EHD within 60 days <br /> unless otherwise specified in the IR. <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: 4/r vlo 6 Inspected By: Sfeve" Sh t h <br /> Sz'o E, LoVi`Se / Av, <br /> Facility Address: 1—ec) nao (A gs330 EPA ID#: Cd}D ©US'¢ 15-6 3 <br /> I 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. I 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 /> ) P7 cC,'jj' l`C'S th P2r� <br /> Name: /d �6�{2 Title: LnvrYY�rrht� /S�cr�(��f <br /> Signature:r Date: <br /> EHD 22-02-005 Rev 12-04 <br />