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Dec 16 11 08:54a Calif Specialty Cheese 209 858 9599 p.3 <br />SAN JOAQUIN CouNTV <br />E'NVlRONMMvrAL HEALTH DEPARTMENT <br />600 E. Main St., Stockton, CA 95202-3029 <br />7elepkvne. (209) 468-3420 Far: (209) 468-3433 Web;v.or hd <br />RETURN TO COMPLIANCE CERTIFICATION <br />Any M IN -OR violations noted in the "Notice to Comply" in the attached Inspection Report inust be <br />corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br />F.nvirozunental 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 otberwise specified in the Inspection Report, <br />Note: All EHD staff time associated with failing to comply by the above noted dates will be billed at <br />the current hourly rate (5125). <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 />a Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br />verifying corrections <br />Operator's certificution <br />Inspection Date: Inspected By: il)1 <br />Facility Address: 111Q,�T j _S r'r �� � �/ EPA ID#:_C4-L 610�27 y1&?l <br />I certify under penalty of law that; <br />1. 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 Paperwork Statement <br />3. 1 am authorized to submit this certification on behalf of the Respondent. <br />4. i ani 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—'a ,. k,J Title: <br />Date: <br />FHD 22-02-005 Rev 08/10 <br />