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RPR 15 2010 19:05 FR TO 9'/_39816293[R M2{�n n�® <br /> SAN JOAQUIN COUNTY �UUuUU1 (�V"I1 1111�C\/// <br /> ENVIRONMENTAL HEALTH DEPAR MEN'r k19( 12 ���� <br /> 600 E.Main St.,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www A os v.or81eha ENVIRON: LENT HEALTH <br /> PERWLSERViCES <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 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 MID staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate ($105). <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: �3 Z /U Inspected By: tc-tC ((C " ve-. <br /> Facility Address: �53� C. Ps�wd evn ��� EPA ID#: QL 0000 3 <br /> T"c� CA <br /> I certify under penalty f law that: <br /> I. 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 Paperworkstatement <br /> 3. <br /> 3. I am authorized to submit this certification on behalf of the Respondent. <br /> 4. lain 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: k h 2v 1e Title: ✓• lso\r— vlvseve, crJ <br /> Signature: - Date: � /0/1 0 <br /> EHD 22-02-005 Rev 10-07 <br />