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06/09/2010 14: 50 20992933919 KIM POTTS PAGE 01103 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTiI DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> WW_sigov.orq/eh.0 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:W <br /> JUN 0 9 2010 <br /> RETURN TO COMPLIANCE CERTIFICATION SAN j c(),jgry <br /> E_' .1 <br /> ,�4'' "2,%�'ENTAL <br /> n the "Notice to Comply" in the attached Inspection Report must be'�� L-(H Drz-AP <br /> Any MINOR violations noted i his certification form must be submitted to the P -TMENT <br /> corrected within 30 days of receipt Of this inspection- This f receipt of the <br /> Environmental Health Department (EHD) address at the top of this form within 30 days o <br /> Inspection Report- <br /> All <br /> eportAll 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 <br /> within 30 dans <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 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, Inspected By:R( 01)1 <br /> Facility Address: % EPAID#: 000as <br /> Inspection E� <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 Paperwork­7�L Statement <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, including the <br /> possibility of a fine and/or ' i �qnment for known violations. (HSC 25191) <br /> impris <br /> Title: <br /> Name: Date: <br /> Signature: <br /> EHD 22-02,Coi Rev 10/09 <br />