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SAN JOAQH COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax,(209)466-3433 Web:www.siaov org/ehd s <br /> Fp <br /> RETURN TO COMPLIANCE CERTIFICATIo° <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report musCl� <br /> corrected within 30 days of receipt of this inspection. This certification form must be submitted to <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 certi <br /> fication / <br /> Inspection Date: .7 "-2 7 — Z0I1 ,/ Inspected By: <br /> Facility Address: 71911 5. dt,rt�r WAV EPA ID#: C.44 00027M00 <br /> S roe-le-7-01^/ Ca <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 K� 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 25191) <br /> Name: '�1 IGK ��G S o/�/ Title: (;. F. 5. Yz- <br /> Signature: Date: <br /> EHD 22-02-16O Rev 08/10 <br />