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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTML <br /> 600 East Main Street, Stockton, CA 95202-3029 j <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.siaov.ora/em i �, R <br /> RETURN TO COMPLIANCE CERTIFICATIO2010 �. <br /> M� Y ' '1U VCoUh'� <br /> � <br /> Any MINOR violations noted in the "Notice to Comply' in the attached Inspection Report m�uslt4r <br /> corrected within 30 days of receipt of this inspection. This certification form must be submitted to thNr <br /> Environmental Health Department (EHD) address at the top of this form within 30 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 <br /> billed at the current hourly rate of $105 (beginning 8/1/09 the hourly rate will be $115). <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 /> Inspection Date:—LL � Inspected Sy: W <br /> Facility Address:2 q 7 ) %1116"4,/Ld EPA ID#: 641 &41 ) "44" 3 <br /> di . <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 andI believe the informationto be true, accurate, nd complete: <br /> . <br /> ,IelPhotos "P perwork 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 imprisonment for known violations. (HSC 25191) <br /> Name: Title:.�d-1-11 -. <br /> Signature: Date: <br /> EHD 22-02-005 Rev 06/09 <br />