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07/1Ju1. 19. 20108 7: 27AMx 20GOIA" State Irrigation No. 0390 P. 2/2i02/002 <br /> SAN JOAQUIN COUNTY <br /> EN V IRONM ENTAL HEALTu DEPARTMENT <br /> 600 Exist Main Sheet,Stockton,CA 95202-3029 <br /> Telephone.,(209)468-34201 ar:(209)465-3433 WaG; �[.)X�jgQv,Qrg/ghd <br /> RETURN TO COMPLIANCE CERTIFICE4TION <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 Irl+l)staff time associated with failing to comply by the above noted dates will be billed at <br /> the current hourly rate($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: UI b Inspected 13y: �CO 1-C S?L1/A <br /> Facility Address: 164% til. SI+ArW Ro_ FPA ID#: CALa6 11i 49Ty _ <br /> I certify under penalty of law that: <br /> I. I have corrected the violations specified in the Inspection Report fi-om 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 Paperwork 1/ Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respondent. <br /> 4, I am aware that there are significant penalties for submitting false information, inclpding the <br /> possibility of a fine and/or imprisonment for known violations, (HSC 2519 1) <br /> Name: JCo• Title.--GM <br /> Signature: s Date: <br /> EHD 22-02-005 Rev 11/07 <br />