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Oct 18 10 06:49p Franoene Escobar p �n� 2098254539 PA <br /> g / �r _JOAQUIN COUNTY r� r <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd d , <br /> 4 <br /> RETURN TO COMPLIANCE CERTIFICATION` 118 2010 <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 30 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 <br /> billed at the current hourly rate. <br /> For this Certification t0 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 resultsfmanifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: (Q f/�/2 -0" D Inspected By: r A e4,j,, <br /> Facility Address: -17 r S�!'t� �� EPA ID#: CQ 0V QCi `] O/_2� <br /> I certify under penalty o aw t a ' _1t!of <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and 1 believe the information to be true, accurate, and complete: <br /> Photos Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware that there are significant penalties for submitting false information, including the <br /> possibility of a fine andlor imprisonment for known violations. (HSC 25191) <br /> r <br /> Name:_ T_raAme AI�P ��7 C C la Title: <br /> Signature- <br /> Date.- <br /> EHD <br /> ignaturDate:EHD 22-0&005 Rev 10.'09 <br />