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DEC-16-2009 07:59A FROM:KRAGENI 2094770158 TO:4683433 P.2/7 <br /> LZ/Ua/2UU9 Toe L][44 NAX 21 �UJGJJ UJe LHU IOJUUL/UUZ <br /> SAN JOAQUIN COUNTY j <br /> ENVfaONMENTAf,HPALTH DEPARTMENT <br /> 600 Hast Main Sim"Stockton,CA 95202.3029 <br /> 7elephvn=(209)468-3420 Fez:(209)468-3433 Weh:WWw.51 v.or .£1{Q <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> l <br /> AnyIM NOR 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(Invs <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 billed at <br /> the current hourly rate ($105). <br /> For this certification to be complete the operator of the site mast include: <br /> • A statement dotumenling what corrective actions were taken or wilt be taken for each violation <br /> • Copies of sample results/manif-ssts/training recools/olher appropriate paperwork,and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: N�� lt� 7Opcl Inspected By: <br /> Facility Address:IAD!4 {''h 5, EPA [DO: 110 02U <br /> I certify under penalty of law that: <br /> I I have corrected the violations specified in the Inspection Report from 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 Statement <br /> 3. I am authorized to submit this certification on behalf of the Respondent, <br /> 4, [ 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 AAA a, AS c �/►/Irng2 <br /> Signature: Date: L 410cl <br /> EHD 22-02-005 Rev 11107 <br />