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SAN JOAQUIN COUNTY R��CI <br /> ENVIRONMENTAL HEALTH DEPARTMENT CED <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fox.(209)468-3433 Web:www.sigov.org/ehd JUL 14 2011 <br /> E <br /> PERMIT/gERVI t LTH <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 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 35 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 billed at <br /> the current hourly rate($122). <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 results/manifests/training records/other appropriate paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> F <br /> pection Date: JJ,., (� 2 0 11 Inspected By:ility Address: 3 f �, L�,uN„ L S,f_ /ate EPA ID#: Ltl L00000 199 <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 PaperworkStatement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4. 1 am aware hat there are significant penalties for submitting false information, including the <br /> possibili a fine and/or imprisonment for known violations. (HSC 2519 1) <br /> Name: �� Title: <br /> Signature: Date: <br /> EHD 22-02-005 Rev 08/ 0 <br />