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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTFiDEPARTMENT <br /> 304 East Weber Avenue,P Floor,Stockton,CA 95202-2708 - <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjjZov.org,/ehd <br /> RETURN. T6COMPLIANCE CERTIFICATION <br /> jiv, <br /> Any MIN012 viotations noted m the"Notice to Comply"m the attached inspectnou repori must be <br /> corrected within 30 days of receipt of this mspechon':,This cert�ficah'on form must be'subinifiM to the ; <br /> Environmental Health Department(EHD)address ai 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 Ins echon Report(IR or Continuation <br /> Form,or <br /> disputes to any violations,are to be submitted using this certification:arid 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: /� Q(�, Inspected By:&, <br /> • <br /> Facility Address; 757 lam} IEL /[Uff EPA ID#:CAL (XW1%e DQ <br /> I 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. - <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 2519 1) <br /> Name:_� , Title. t 11V vj/l�r6 tWEZ <br /> Signature: 4k�, z y Date: o(, ~ <br /> EHD 22-02-005 Rev 12-04 <br /> I -d T696-BLib (602) LLZfr# ijeW-A et,Z :BO 90 92 AoN <br />