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0 SAN JOAQUiN COUNTY <br />El NVIR-ONIALN't'AL HE ALTH DEPARTME NT <br />600 L. Main St., Stockton, CA 95202-3029 <br />Teiephajie: (209) 469-3420 Fax: (209) 468-3433 Web: w�-vwsjgpy.orgkh.d <br />. ......... . . <br />RE TURNT TO COMPLIANCE CEWfIFICATION <br />A.ny M IN OR violations noted in the "Notice to Comply". in the attached Inspection Report must be <br />curccc;-t.edwithin 30 days of receipt of this inspection. This certification form m-usi be submitted to the <br />Eavirownei-ital Health Department (EI -ID) address at the top of this form within 35 days of receipt of the <br />Inspection Deport. <br />All.cc,ri-ecliofis to other violations rioted in the attached Inspection Report or Continuation :Corm, or <br />dli&fAittS to any violations, are to be subiniaed using this certification and rerurned to EI -ID willail 30 Clays <br />unless otherwise specified in the Inspection Report. <br />N&iir: A ki E11D staff tiale us&aciawd with failhig to comply by the 2tbove noted daUs will be billed. at <br />the eueve"i 110jurly rate ($98). <br />For dils ceftitication to be coni plett the operator of the site must include: <br />A statement documenting what corrective actions were talcen or will be taken for each violation <br />Copies of sample resLilts/ftiaiiifests/tr,,iiiiiiig records/other appropriate paperwork, arid/or photos <br />verifying corrections <br />Operator's certification <br />Inspection Date: �5=A 2-/0 F,;, Inspected By: RA y v0V I—AGIC <br />Factilly Address: (0 t6 S. Lt/t tsv,%, itIA1,- EPA ID#: C,,4DC1 IS- 9,3 6 15-5- c -k <br />0 <br />I certify under penalty of law that: <br />1. 1. have corrected the violations specified in the Inspection Report from the above-mentioned <br />ifispectloa date. <br />2. 1 have personally examined the following documentation submitted as proof of compliance FOR <br />EACH VIOLATION and I believe the inforination to be true, accurate, and complete: <br />Photos Paperwork L,,"'Statement <br />3. 1 airs authorized to submit this certification on behalf of the Respondent. <br />4. 1 ant aware that there are significant penalties for submitting Ealse information, including the <br />possibility of a fuse and/or inip-risoninent for known violations. (HSC 25191) <br />thane: ) Title: <br />Si <br />EHD 22-02-005 Rev 10-07 <br />r. Date: <br />