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05-03-'12 10:25 FROM- T-363 P001/007 F-839 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT MAY 0 2012 <br /> 600 East Main Street, Stockton,CA 95202.3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ohd <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 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 EMD within 30 days <br /> unless otherwise specified in the Inspection Report, HSC 25185(c)(3) <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 certificationl <br /> Inspection Date: r / 5/ 12— Inspected By:Stacy Rivera <br /> Facility Address: —Isl &Oj tw o„y EPA IDN: CAI OoU 3o 41�()2)2. <br /> 1 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. 1 have personally examined the fallowing documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true,accurate, and complete: <br /> Photos d 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, (HSG 25191) <br /> Name:—A I be Kk Am!e2 Title: I ANV�A ar✓ <br /> _ <br /> Signature: Date: <br /> EHb P2 2-005 Rev OW11 <br />