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DEC-2-2010 16:14 FROM: TO:4683433 P.2 <br /> I <br /> • SAN JOAQUIN COUNTY RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 I <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.s aol V ora/ehd NOV 0 9 2010 <br /> FWRONUFaTA1 WEALTH <br /> PERMIT/SUMCIE8 <br /> RETURN TO COMPLIANCE CERTIFICATION o III <br /> Any MINOR violations noted in the "Notice to Comply° in the attached Inspection Report must be <br /> i <br /> corrected within 3Qdays of receipt of this inspection. This certification form must be submitted toithl;2010 <br /> Environmental Health Department (EHD) address at the top of this form within 30 days of receipt of the <br /> Inspection Report. wrt <br /> All corrections to other violations noted in the attached Inspection Report (IR) or Continuatiori dorm, of <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 tlme 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: " L5 I Inspected By: <br /> Facility Address:.4L Z1�l SI EPA ID#: ` <br /> I <br /> I certify under penalty of law that: i <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentioned <br /> Inspection date. j <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 /> PhotosPaperwork Statement j <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> i <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- (HSG 25191) <br /> r <br /> Name: ) lA j ` e-+. Title: (Ltal-,.av- <br /> Signature: I _ p,�,� as L Date: - K7 <br /> i <br /> EHD 22-02-0D5 R"10/09 <br />