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SAN JOAQU[v COUNTY <br /> ENv1F,ONMENTAL HEALTH DEPARTMENT <br /> 600 E.Main St., Stockton,CA 95202-3029 <br /> Telephone.(2o9)464-3420 Fax:(209)468-3433 Web. ;=NT�tl��hd <br /> MAR 1 7 MI. <br /> RETURN TO COMP'L 4,NCE CERT1YWAT1ON g <br /> An MINQR violations noted in the"Notice to Comaply"in the attachT ItiSpectioz� Report must be <br /> y�-- <br /> corrected within 30 da of receipt of this inspection...This certification form must be submitted to le <br /> Environmental Health Department(EHD) address at the top of tliis form within 35 days of receipt of the <br /> Inspection Report. <br /> All coKEgctions to other violati ns noted in the attached Inspection Report or Continuation Form, or <br /> disputes to any violations, are to be submitted using this certificatian and returned to ETrID within 30 da s <br /> unless otherwise specified in the hispectioii Report. <br /> Note, All E13D staff time associated with failiwg to comply by the above noted dates will be billed at <br /> the current hourly rate ($1:22). <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 eachviolation, <br /> • Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • operator's certification <br /> inspection Date: *JR Inspected By: Stacy iyera <br /> Facility address: i - EPA IDS: <br /> I ceztify under penalty of law that: <br /> 1. I have corrected the violations specified in the Inspection Report firom 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 /> Statement <br /> Photos—AZPaperwork � <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. �SCc;6 eaz\ <br /> 4. I am aware that there are significant penalties for submitting false information,including the <br /> possibility of a fine and/or imprisomuent for known violations. (HSC 2519 1) <br /> Title: <br /> Mame: <br /> Signature: <br /> Date: <br /> EHD 22-02-005 Rev 08/10 <br />