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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.slgov.org/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 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 30 days of receipt of the <br /> Inspection Report. HSC 25404.1.2(c)(1) <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. HSC 25185(c)(3) <br /> Note: All EHD staff time associated with failing to comply by the above noted dates will be <br /> billed at the current hour) rate. <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 certificationPn/ Q� <br /> Inspection Date: ` � i Inspected By: 4� `-0� <br /> r <br /> Facility Address: � l APine—P, EPAIM: C&0MSLH ZYY <br /> r 1A <br /> I certify under perlrltyy<f 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,gf gompliance FOR <br /> EACH VIOLATION and I believe the information to be true, accurate, and coirilowb:, <br /> Photos Paperwork_Statement <br /> FEB ® 2012 <br /> 3. 1 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, in �Ii}� ENTAL <br /> possibility of a fine and/or imprisonment for known violations. (HSC 25191) ' TME"v i <br /> Name- To liv, A Ye o\!� Title: Vy)q%v\c E r <br /> Signature: 4;4k r Date: -a- <br /> �1'a 1 K `t (_�� , s-� r'�e-� t er A lA o LA t Scr.o ra14'`l <br /> EHD 22-02-005 Rev 09111 r.. <br /> T l0a — oo �l n e s w , 11 'b D;S o e� 6 -� a <br /> 'M e <br /> ' • 501, 5p ;�le� G �esGl � Oil_ <br /> C, 0 -n JC a M 1 n c"`I' e-6 i c,s're. <br /> E c lmac.v� �1 <br /> -AV d 16 ,s �bS e-4 o4 a.5 1117 W <br /> o �4� �' � ,7 (ac s -A1 R I e c)��` �h^ry,,n�-�as �e w ill LQ <br /> sen* -to <br />