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ENVIRONMENTAL HEALTHD COUNTY <br /> RECEIVED <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sj og v.or /ee JUL 12014 <br /> ENVIRONMENTAt EALTH <br /> PERMITISERVICES <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 30 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate($122). <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: IV Inspected By: IrFp <br /> Facility Address:313�V .W 11 j lJ U EPA ID#: e�.AUj)?)0062i S <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 XStatement <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: (r,)&oMX.) Title: DU <br /> Signature: Date: _ S <br /> EHD 22-02-005 Rev 08/10 <br />