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SAN JOAQUIN COUNTY <br /> 'It IENVIRONMFNTn I..HFALTH DEPARTMENT <br /> 600 Easl Main Street.Stockton.CA 95202.3029 <br /> Telephone:(209)46k-34:'11 Fox:(209)468-3433 Web:rywwsjov.orpJeh(1 - <br /> DEC 0 12010- <br /> RETURN TO C'0MPLIANCE CERTITICATIOI` AENV(Ii,:',;,; >tiTAL <br /> HEALTH DEPA,,:ITMENT <br /> Any MINOR violations noted in the"Notice Tu Comply" in the attached Inspection Reportmust be <br /> corrected within 30 daya of receipt ofthis inspection. This certification form must be submitted to the <br /> Environmental Health Department(EHL)) oddress at the top of this form within 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to other violations notal in the attached inspection Report(IR)or Continuation Forrn, or <br /> disputes to any violations,are to be submitted using this certification and returned to EH.D within 30 days <br /> unless otherwise specified in the Inspection Report. <br /> Note: Alt EFiD staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate ($11.5). <br /> For this certification t0 becomplete the operator of the site must include: <br /> • A statement documenting what corrective actions were taken or will betaken for each violation <br /> • Copies of sample results/manifc�ts/Training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date; — U . ._. Inspected By: <br /> Facility Address: g 41 _.Z rr7 EPA ID#: -- <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations speci liccl in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined the Billowing documentation submitted as proof of compliance FOR <br /> EACH VTOLATION and T believe the information to he true, accurate, and,complete: <br /> Phok)s Paperwork—X—Statement <br /> 3. [ am authorized to submit this certification on behalf of the Respondent. <br /> 4. lam aware that there are significant penalties for submitting false information,including the <br /> possibility of a.fine and/or impri.urnnrent for known violations.(HSC 25191) <br /> Name: Title: ((] �c <br /> Signature: <br /> Date: <br /> EHD 22-02-005 Rev 11/07 <br />