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AUG-20-2010 09:36 FROM:MONKEY'6 ^'1TO & RV I 2092394618 `4683433 P. 1/1 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209) 468-3420 Fax: (209)468-3433 Web:www.s' ov. r /ehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the "Notice to Comply" in the attached Inspection Report must be <br /> corrected within 30 da sof receipt of this inspection thetopcertification <br /> form <br /> within must <br /> 30 days of receipt of the <br /> Environmental Health Department (EHD) address a P ofthis form <br /> Inspection Report. <br /> All corrections to other violations noted in the ahthisncertificationion eContinuationport (IR) or <br /> and returned to EHD within 30 da s <br /> using disputes to any violations, are to be submitted g <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 CG'rtIfIGBt1011 t0 be COI'Y1pletE%re takenhe roror of the site must will be taken for each violation <br /> • A statement documenting what corrective action <br /> • Copies of sample results/manifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspectrlon Date: �- Inspected By: h U-� I r <br /> Facility Addre <br /> (� r (� ' PA ID#F: <br /> ss: <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 /> inspection date. <br /> 2. 1 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. I 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 and/or imprisonment for known violations. (HSC 25191) <br /> Name: ^�i �, n .1 f J_L Title: <br /> Signature' <br /> '� ' r Date: t <br />