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SAN JOAQUIN COUNTY RECENED <br /> ENVIRONMENTAL HEALTH DEPARTMENT �� ���� <br /> 304 East Weber Avenue,3dFloor,Stockton,CA 95202-2708 - <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sigov.org/ehd [MYR MENT 'HEAb H <br /> RETURN TO COMPLIANCE CERTIFICA.TION <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 60_days <br /> unless otherwise specified in the IR. <br /> For this certification t4 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 4-0tn P <br /> t \ h <br /> Inspection Date: - .9,4-fl? Inspected By: a. c�,.vt <br /> Facility Address: a3 IS o e m EPA IIS#: <br /> Pn V,L CC-� <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 Dave 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 Z 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 r <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) <br /> Name: 0.(>,Voo, Title: 0�4 o tri' <br /> Signature:0,j w „' - _ Date: -0-7 <br /> EHD 22-02-00 Reevv 12-04� <br /> �I] @ n VI VA 0 Y %fa i7� � ira . � p <br />