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01/27/2010 17:55 2093697813 WINE COUNTRY STATION PAGE 01 <br /> SAN JOAQUIN COUNTY��S. dg <br /> ENVIRONMENTAL HEALTH DEPRretM'�hj �W <br /> 600 East Main Street, Stockton,CA 95�47p29 j <br /> Telephone: (209)466-3420 Fax: (209)468-34x3 Web; !eh <br /> - AN 2 g 2010 <br /> sr Al <br /> Y�4 t✓,h'a�zwf YOA <br /> RETURN TO COMPLIANCE CERTIFI ''IATFOIJ'�'DE� TareNr <br /> Any MINOR violations noted in the "Notice to Comply" in the at*hed Itiopeolo. Report must be <br /> corrected within 30 days of receipt of this inspectioh. This certmcation foaIgm ot'be submitted to the <br /> Environmental Health Department (EHD) address at the top of this form Within$6.days of receipt of the <br /> Inspection Report. <br /> I r <br /> All corrections to other violations noted in the attached Inspection RepQl Qk)qr Continuation Form, or <br /> disputes to any violations, are to be submitted using this certiflpatlon 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 this above noted dates will be <br /> billed at the current hourly rate. <br /> For this certification to be complete the i pperatororthe site"must include: <br /> • A statement documenting what corrective actions were taken or 41 be for each violation <br /> • Copies of sample results/manifests/training record_slother appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: I�- I •,2cU4 Inspected : �o�:►i i/Dh P1uQ <br /> Facility Address:AS� <br /> I certify under penalty of law that: <br /> I: <br /> 1. I have corrected the violations specked in the Inspection Reportfrolm(the abobe-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 end complete: <br /> Photos Paperwork lstatement <br /> 3. 1 am authorized to submit this certification on behalf of,the Respondent. <br /> 4. 1 am aware that there are significant penalties forsubMittin4 false information, including the <br /> possibility of a fine and/or imprisonment for known violations (K90'g$191) <br /> Name: ln Title;v_D _ <br /> Signature: ��✓ D <br /> EHD 22-02-005 Rev 10109 . <br />