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P. 1 <br /> • Communication Result Report ( Dec, 5. 2012 ' 3: 28PM ) <br /> 1) San Joaquin County <br /> 2) Environmental Health Department <br /> Date/Time: Dec. 5, 2012 3: 27PM <br /> File Page <br /> No. Mode Destination Pg (s) Result Not Sent <br /> ---------------------------------------------------------------------------------------------------- <br /> 0359 Memory TX 98258059 P. 1 OK <br /> ----------------------------------------------------------------------------------------=----------- <br /> Reasonfor error <br /> E. 1) Hansup or line fail E. 2) Busy <br /> E. 3) No answer E. 4) No facsimile connection <br /> E. 5) Exceeded max. E—mai 1 s i z <br /> SAN JOAQUIN COU4n <br /> ENVIROMM-TrAL HEALTH DEPARTMPM' <br /> 304 Eaan\Veber A--3'0 M..Stockton,CA 952¢-27118 <br /> Tdepbarc(209)466-3420 F—(209)4693433 epee:www.cieov ora/" <br /> RETURN TO COMPLL#NCE CERTIFICATION <br /> Any MN violations noted in the"Notice to Comply"in the atW-Ikcd inspection report must be ' <br /> corrected within 30 dava of receipt of this inspection.This certification form must be submitted to the <br /> Environmental Health Department(HHD)address ra the bop of this form within 35 days of receipt of the <br /> inspection report. <br /> All corrections to other violations rated in the attacbcd Inspection Report(ll)or Cottnamtion Form,or <br /> disputes to any violations,are to be suhmrtled using this certification and returned to FAD within 60 days <br /> unless otherwise specified in the IR. <br /> For this certification to be complete the operator of the site must includes <br /> • A statement documenting what corrective actions were falcon or will be taken foe each violation <br /> • Copies of sample results/mffitifuests/training records/other appropriate paperwutk,andlor photos <br /> verifying corrections <br /> • Opetatur's cvtific rtion <br /> Inspection Date: -3 nW I I2 Inspected By: Wt•AAW>,-t <br /> Facility Address: It e a S Main Li a Mwtku EPA ID#: <br /> I certify under penally of law that <br /> 1. I have corrected the violations specified in the Inspection Report from the above-mentionW <br /> inspection data <br /> 2. I have personally examined the followiag doeumenlaticat submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe die information to be true,accurate,and complete: <br /> Mtotos n/ Papcaari ✓_Statenront <br /> 3. I am authorized to submit this certification on behalf of the Respondent" <br /> 4. I am aware Owl there arc significanl penalties for submitting false information,including the <br /> possibility of a tine and/or imprisonment for known violations.(HSC 25191) <br /> Name: Title: <br /> Signature: Dau: <br /> ERD 22-02-005 Rea 12.94 <br />