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2013-06-12 02: 14 2600 2098302954 » P 6/6 <br /> SAN JOAQUiN COUNTY <br /> ENVIK(1NMENTAI. HEALTH DI,.11ARTMEN1' <br /> 1868 E.Hazelton Ave., Stockton,CA 95205-6232 <br /> Tele Jhotre: ( ) <br /> / {,.09)A68-3420 Far: Zf19 468-3433 Web:ama,si�ov.org/eh <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> AnyN11NIOR violations noted in the"Notice to Comply" in the attached inspection Report must be <br /> corrected witl>in 3{)days of receipt of this inspection. This certification form must be submitted to the <br /> F.nvirom-nental Health Department(LH D) 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 EHD staff time associated with failing to comply by the above noted dates will he billed at <br /> the current hourly rate ($125). <br /> For this certification to be complete the operator of the site must include: <br /> • A statement documenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: /Z- Inspected yH <br /> Facility Address. W /( �h�q EPA ID#: 4094-0002$qv57 <br /> I certify under penalty of law that: <br /> 1. i have corrected the violations specified in the inspection Report fiom the above-mentioned i <br /> inspection date. <br /> i 2, I have personally examined the following;documentation sribnlitted as prool'of compliance FOR <br /> EACH VIOLATION and i believe the,inlon-nation to be true, accurate, and complete: <br /> Photos l/ Paperwork Statement i <br /> 1 — <br /> 3- i aui authorized to submit this certification on behalf of the Respondent. <br /> 4, I am aware that there are significant penalties for submitting false information., including the � <br /> possibility- of a fine and/or imprisonment bor known violations. (IISC25191) <br /> Name: f� l7 T� Title:�G�i 6-( C <br /> Signature: Date_ <br /> iron nO (%A 1Z r n A-, <br />