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Jan. 21, 2013 1 36P No. 0100 P. 1 <br /> SAN EA COUNTY RECEIVED <br /> ENVIRONMENTALTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, California 95205-6232 <br /> Telephone:(209)468-3420 Fax.(209)486-3433 Web:www.sigov.org/ehd JAN 2 2 2013 <br /> ENVIRONMENTAL <br /> RETURN TO COMPLIANCE CERTIFICATION HEALTH 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 30 days of receipt of the <br /> Inspection Report. HSC 25404.1.2(c)(1) <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. HSC 25185(c)(3) <br /> Note; All F-HD staff time associated with failin.9 to comply by the above noted dates will be <br /> billed at the current hourly rate. Lit <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 /> B <br /> Inspected �n <br /> Inspection Date: l2_�� ^ �� � ins p y' UM IV� -- <br /> Facility Address:-110 I 06fltEPA lD#: Qqo�L00b <br /> W-�Ivb P i ch <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, 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 "ccStatement <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 /> �(f�l� ,�< < Title: <br /> Signature: -r.� <br /> �� � Date: <br /> EHD 22-02005 Rev 04/19112 <br />